LIBRARY OF CONGRESS. 

Chap.- Copyright No. 

Shelf„y_S._5) 



UNITED STATES OF AMERICA. 



A CLINICAL TEXT-BOOK 



MEDICAL DIAGNOSIS 



PHYSICIANS AND STUDENTS 



BASED ON THE MOST RECENT METHODS OF EXAMINATION 



BY 



OSWALD VIKRORDT, M. D. 

Professor of Medicine at the University of Heidelberg ; Formerly Privat-docent at the 

University of Leip^iig ; Later, Professor of Medicine and Director of 

the Medical Polyclinic at the University of Jena 



AUTHORIZED TRANSLATION 

WITH ADDITIONS 

BY 

FRANCIS H. STUART, A.M., M. D. 

Member of the Medical Society of the County of Kings, New York ; Fellow of the New York 

Academy of Medicine ; Member of the British Medical Association ; Ex-President of 

the Brooklyn Pathological Society ; Obstetrician to the Brooklyn HospitaL etc. 

FOURTH AMERICAN EDITION, FROM THE FIFTH GERMAN 
REVISED AND ENLARGED 



With One Hundred and Ninety-four Illustrations 



PHILADELPHIA 

W. B. SAUNDERS 

925 Walnut Street 
1898 



7^ 



;N Co^-" 



13681 



Copyright, 1898, 
By W. B. SAUNDERS 




Trt. •> 



ntUtlVED. 






ELECTROTYPED BY 
WESTCOTT & THOMSON, PHIUADA. 



PRESS OF 
W. B. SAUNDERS, PHILADA. 




189B. 



TRANSLATOR'S PREFACE TO THE FOURTH AMERICAN 

EDITION. 



Professor Vierordt's " Diagnostik der Innerer Krankheiten " has 
created and met a demand which is remarkable in- medical literature. 
Less than nine years elapsed between the date of the first edition and 
that of the fifth, from which the present translation is made. During 
this period the progress in various departments of diagnosis has been 
great, but the book has been kept fully abreast of this progress : the 
Author has carefully revised his work four times. 

Upon its first publication it was immediately translated into Russian 
and Italian as well as into English, and was welcomed by the medical 
profession in all parts of the globe. 

It will be found that all the qualities which made the earlier editions 
so acceptable have been developed with the evolution of the work to 
its present form. A distinguished professor of medicine who also has 
a large consultation practice once said to the translator, " I have never 
read a medical work from which I derived so much profit as from 
Vierordt." It is a veritable mine of information on all points in medi- 
cal diagnosis. 

It is therefore a great pleasure for the translator to present to the 
English-reading medical public this fourth edition. The labor for one in 
active practice has been great, but it is ample reward to have thus kept 
pace with the diligent author by bringing the work up to date in its 
EngHsh dress. What was first sent forth with fear lest the judgment 
of others would not be consonant with his own/is now given with 
assurance that it will meet with a still warmer welcome by reason of 
its enhanced and inherent excellence. 

FRANCIS H. STUART. 

123 JORALEMON STREET, BROOKLYN, NeW YoRK, N. Y., 

August I, 1898. 



AUTHOR'S PREFACE TO THE FOURTH AMERICAN 

EDITION. 



In the first place, it gives me pleasure emphatically to express my 
approbation of Dr. Francis H. Stuart's translation of my work upon 
Diagnosis as being accurate and excellent in every respect. I rejoice 
in its great success. 

The present edition in English is translated from the fifth German 
edition, for which I furnished advance sheets. Many alterations have 
been made throughout the book, but especially in the sections on Gas- 
tric Digestion and the Nervous System. 

The particular purpose of my work is to furnish the physician with 
the material by which he may make himself an accomplished diagnos- 
tician in all branches of medical diagnosis. The foundation of a cor- 
rect diagnosis must rest upon a careful examination of the individual 
organs, and then a study of the whole organism, the totality of the 
picture of the disease. 

May the new edition in English, to which I wish the same success 
the former editions had, contribute to the attainment of this high end. 

PROF. O. VIERORDT. 

Heidelberg, February 5, 1898. 



PREFACE TO THE FIFTH GERMAN EDITION. 



The new edition has been revised in all its parts, and altered or en- 
larged in many places. The most thorough revision has been made in 
regard to the examination of gastric digestion and the examination of 
the nervous system. Fourteen new illustrations have been added, and 
a few former ones have been replaced by ones more suitable. For a 
part of these I have to thank my former assistant, Dr. Becker. 

That we have for the present altogether omitted the application of 
Rontgen rays for the purposes of internal medicine, which is still in its 
first beginnings, will no doubt be approved by every reader. 

Nevertheless, a not inconsiderable enlargement of the book could 
not be avoided. I hope that this enlargement will also be considered 
an improvement. 

O. VIERORDT. 

Heidelberg, February, 1897. 



translator:s preface. 



The work of which a translation is here offered is one of the best 
that has yet been written upon the subject. When it first came into 
the hands of the translator he had no thought of ever using it except 
as a work of reference. But as he read it he became convinced that 
it had such merit that it would certainly be welcomed by a large class 
of readers if it were rendered into English. Accordingly, after com- 
municating with the author and his publisher, the work of translation 
was begun, and has been prosecuted at such intervals of time as could 
be secured from an active professional life. If the work shall com- 
mend itself to others as it has to him, the translator will feel amply 
rewarded for the effort he has made to put it into their hands. 

Here and there slight additions have been made, which the trans- 
lator trusts will increase the value of the work. A very full index 
has been prepared, which, it is believed, comprises a reference to every 
material statement in the book. 

The translation was almost completed when a copy of the second 

edition of the original was received from the publisher. The author 

has made numerous additions which have enhanced its value, and the 

translation has been made to correspond with this enlarged edition. 

It is gratifying to the translator to find that a second edition has so 

soon been called for, and that his own favorable opinion has been 

further confirmed by the fact that Italian and Russian translations of 

the work have been made. 

FRANCIS H. STUART. 

123 JORALEMON STREET, BROOKLYN, N. Y., 

March, 189 1. 
6 



PREFACE TO THE FIRST EDITION, 



The book which is here offered to the medical pubHc was under- 
taken at the solicitation of a number of associates, and in view of the 
experience which I have acquired during more than four years of work 
as Teacher of Diagnosis in the Medical Clinic at the University of 
Leipsic. Originally I had in view a very extensive treatise comprising 
a detailed explanation of normal and pathological anatomy and physi- 
ology as a foundation for diagnosis. But this plan I abandoned with a 
view to the convenience and general usefulness of the book. 

Regarding the principles which have guided me, and which I hope, 
particularly in the " Special Part," notwithstanding the brevity of the 
presentation, have been made plain, I may be permitted here to specify 
the following. I have here, as well as in my teaching, taken pains to 
emphasize that, besides availing ourselves of the constantly-increasing 
finer methods of diagnosis, the simple use of our senses, especially 
of the unaided eye, must not be forgotten. Still more, the manifold 
labors with the microscope and in the laboratory ought not to permit 
the physician to forget that a preparation or a chemical reaction is not 
enough for a diagnosis, but that the whole organism must always be 
brought under consideration. In other words, in diagnosis as well as 
therapeutics this rule is imperative : We must individualize the case. 
Should the book to any extent antagonize the inclination of our time 
to theorizing, it would afford me especial satisfaction. 

OSWALD VIERORDT. 

Leipsic, June, 1888. 



CONTENTS, 



PART I. 



CHAPTER I. 
Introduction. 

PAGE 

Anamnesis 19 

Mode of Taking the Anamnesis 19 

What the Anamnesis Comprises 20 

Previous History of the Patient 20 

The Present Disease . , 22 

CHAPTER II. 

Examination of Patients. 

What the Examination Comprises . 24 

Note by the Translator upon Keeping Records of Cases, and a Form for Recording the 

Results of a Medical Examination 24 



PART II. 

CHAPTER III. 

General Examination. 

I. The Psychical Condition of the Patient 28 

II. The Position of the Patient 28 

III. The Structure of the Body and Nutrition ; Weight 30 

IV. Skin and Subcutaneous Cellular Tissue 32 

A. The State of Nutrition of the Skin , . 32 

B. The Moisture of the Skin ; Perspiration 32 

C. The Color of the Skin 34 

1. The Pale Skin 35 

2. Abnormal Redness of the Skin 37 

3. The Blue-red Skin, Cyanosis 3^ 

4. The Yellow Skin, Icterus, Jaundice 40 

5. The Bronze Skin 43 

6. The Gray Skin of Silver Deposit 44 



lO CONTENTS. 

PAGE 

D. Other Pathological Appearances of the Skin of General Diagnostic Value . . 44 

1. Acute Exanthematous Diseases 44 

2. Exanthemata from Poisons and the Use of Medicines 45 

3. Hemorrhages in the Skin 45 

4- Scars 46 

E. Edema of the Skin and Subcutaneous Cellular Tissue (Edema, Anasarca) . . 46 

F. Emphysema of the Skin 49 

V, The Temperature of the Body ; Fever 50 

1. The Terms Used and the Method, of Taking the Temperature 50 

2. The Normal Temperature of the Body 53 

3. Elevated Temperature ; Fever 54 

4. The Subnormal Temperature 56 

5. Diagnostic Value of the Temperature, especially of its General Course . 57 

6. Local Elevation or Lowering of the Temperature 65 



PART III. 



CHAPTER IV. 

Examination of the Respiratory Apparatus. 

Examination of the Nose and Larynx 66 

1. The Nose 66 

2. The Larynx 67 

(a) Its Function 67 

{b) The Internal Examination . 68 

Examination of the Lungs 68 

Topographical Anatomy of the Lungs 68 

The Anatomical Boundaries of the Lungs with Reference to the Thorax 69 

Inspection of the Thorax 72 

1. Normal Form of Thorax and Normal Respiration 72 

2. Pathological Forms of Thorax 75 

3. Anomalies of Respiration 79 

[a) Anomalies of the Manner of Breathing 80 

{b) Anomalies of the Frequency and Rhythm of Breathing 81 

(<r) Difficult Breathing, Dyspnea 2)-^ 

Palpation of the Thorax 89 

1. Pain caused by Pressure upon the Thorax 89 

2. Testing the Movements during Respiration 91 

Percussion of the Thorax 92 

General and Preliminary Remarks Regarding Percussion 92. 

1. History and Methods 92 

2. Qualities of Sounds 94 

3. The Conditions that Determine the Quality of the Sounds and their Produc- 

tion in the Body. The Feeling of Resistance 96 

4. Topographical Percussion : Determining the Parietal Boundaries of Organs 102 
Percussion of the Thorax, Especially of the Lungs 103 

I. Methods 103 



CONTENTS. 1 1 

PAGE 

2. Normal Sound over the Lungs, Trachea, and Larynx. The Normal Bound- 
aries of the Lungs 105 

3. Abnormal Sound over the Lungs. Abnormal Position of the Border of the Lungs 109 

A. Diilness : Deadened Resonance 109 

B. Tympanitic Resonance 112 

C. Abnormally Loud and Deep Sound 116 

D. Changed Condition of the Boundaries of the Lungs 117 

Auscultation of the Lungs 118 

1. History. The Sphere of Auscultation at the Present Time 118 

2. Methods of Auscultation 119 

3. Auscultatory Signs in Normal Respiration 121 

4. Pathological Sounds in the Respiratory Apparatus 123 

[a) Alterations of Vesicular Breathing 124 

(^) Bronchial Breathing 125 

(c) Undefined Breathing 127 

{d) Dry Rales (Rhonchus, Humming, Whistling, Hissing) 128 

[e) Moist Rales 129 

(/) Crepitant Rales (Crepitation) 131 

[g) Pleui-itic Friction Sounds 132 

{h) Hippocratic Succussion 133 

Palpation of Vocal Fremitus (Auscultation of the Voice) 133 

Exploratory Puncture of the Pleura ; Diagnostic Study of the Fluid Obtained by Punctur- 
ing - 136 

1. Mode of Procedure 136 

2. Chemical Examination of the Aspirated Fluid 139 

Methods of Measuring and Stethography 140 

Measuring the Thorax 140 

Spirometry, Pneumatometry, and Stethography 141 

Cough and Expectoration 142 

Expectoration, Sputum . 143 

1. General Characteristics of the Expectoration 144 

2. Foreign Substances in the Sputum which are Visible to the Unaided Eye . 147 

3. Microscopical Examination of the Sputum 150 

4. Chemical Examination of Sputum 164 



CHAPTER V. 

Examination of the Circulatory Apparatus. 

Examination of the Heart 166 

Anatomy of the Normal Heart 166 

Preliminary Remarks necessary to Understand the Physical Phenomena of the Heart 167 

Inspection and Palpation of the Region of the Heart 171 

The Apex-beat; Normal Conditions 171 

Alteration in the Width and Strength of the Apex-beat 173 

The Neighborhood of the Heart in General 175 

The Epigastrium 177 

Percussion of the Heart . . 177 

Normal Percussion-figure of the Heart, Methods of Percussion 177 

Enlargement of the Area of Heart-dulness 180 

Diminution or Loss of Heart-dulness 181 

Displacement (Dislocation) of the Pleart-dulness 182 



12 CONTENTS. 

PAGE 

Auscultation of the Heart 182 

Methods and Normal Condition 182 

Pathological Changes in the Heart-sounds 187 

Organic Endocardial Heart-murmurs 191 

Inorganic, Anemic Murmurs 197 

Pericardial Murmurs. [Friction-sounds.] 198 

Examination of the Arteries 201 

I. The Pulse, its Palpation and Graphic Representation 201 

Palpation of the Pulse 201 

, I. The Normal Pulse 201 

2. Pathological Frequency of the Pulse 203 

3. Want of Rhythm of the Pulse 207 

4. Quality of the Pulse 208 

5. Symmetry of the Radial Pulse 210 

Sphygmography of the Radial Pulse 211 

Diagnostic Value of the Examination of the Pulse 216 

II. Other Phenomena in Arteries 218 

The Aorta 218 

The Pulmonaiy Artery 219 

The Other Arteries , 220 

Examination of the Veins 223 

Inspection and Palpation of Veins 223 

1. Increased Fulness of Veins 223 

2. Phenomena of Circulation in the Jugular Veins 225 

3. Phenomena of Circulation in Other Veins 229 

4. Venous Thrombosis 229 

Auscultation of Veins 230 

Examination of the Blood 231 

Preliminary Remarks 231 

1. Color and Spectroscopic Character of the Blood 232 

2. Microscopical Examination of the Blood 237 

1. Alterations in the Number and Appearance of the the Red Corpuscles . 238 

2. Alterations in the Size and Form of the Red Corpuscles 240 

3. Normal and Pathological Conditions of the White Blood-cells .... 242 

4. Abnormal Additions to the Blood 245 

Malaria Parasites 247 

Chemical Examination of the Blood 250 



CHAPTER VI. 

Examination of the Digestive Apparatus. 

Mouth, Palate, and Pharyngeal Cavity 252 

The Mouth 252 

The Lips 253 

The Teeth and Gums 253 

The Tongue 254 

Mucous Membrane of the Mouth 255 

Salivary Glands and Saliva 256 

Microscopical Examination of the Contents of the Mouth 256 

Microscopical and Bacteriological Examination of the Palate and Pharynx 260 

Bacteriological Diagnosis of Genuine Diphtheria 260 



CONTENTS. 



n 



PAGE 

Examination of the Esophagus 263 

Direct Palpation ; Examination with the Sound 264 

Examination of the Stomach 268 

Anatomy of the Stomach 268 

Inspection and Palpation of the Stomach 270 

Percussion of the Stomach 273 

The Halfmoon-shaped Space (Traube) 275 

Auscultation of the Stomach 276 

Illumination of the Stomach : Gastro-diaphanoscopy, 276 

Exammation of the Intestines 277 

Inspection and Palpation 277 

Percussion of the Intestine 280 

Auscultation of the Intestine 281 

Examination of the Peritoneum 281 

Inspection of the Abdomen 281 

Examination of the Liver 286 

Anatomy 286 

Inspection of the Liver 288 

Palpation of the Liver 289 

Percussion of the Liver 292 

Pathological Relations of the Liver 294 

Examination of the Spleen 296 

Anatomy 296 

Inspection of the Spleen . 297 

Palpation of the Spleen • 297 

Percussion of the Spleen 299 

Pathological Relations of the Spleen 301 

Auscultation of the Spleen 302 

Examination of the Pancreas, Omentum, Retroperitoneal Glands 302 

Examination of the Contents of the Stomach 303 

Examination of the Process of Digestion 304 

Preliminary Remarks upon Stomach-digestion and its Disturbances 304 

Absorption 307 

Method of Abstracting and Examining the Stomach-contents 312 

Examination of the Stomach-contents 315 

Results of the Examination of Stomach-contents, and their Significance . . . 323 

Vomiting, and the Examination of What is Vomited 326 

The Act of Vomiting 326 

The Vomit 327 

Examination of the Feces 332 

Intestinal Discharges 333 

Physical and Chemical Peculiarities of the Feces 335 

Animal Parasites 340 

Tape Worm 341 

Round Worms 343 

Trichina Spiralis 345 

Microscopic Examination of the Feces 347 

Chemical Examination of the Feces 353 



14 CONTENTS. 

CHAPTER VII. 
Examination of the Urinary Apparatus. 

PAGE 

Examination of the Kidneys 355 

Anatomy 355 

Local Examination of the Kidneys , . . . 356 

Pathological Conditions of the Kidneys 357 

Differential Diagnosis of Tumor of the Kidney 359 

Examination of the Ureters and Bladder 359 

Examination of the Urine 360 

(A) Normal Urine 362 

(B) Pathological Urine ^66 

Anomalies in the Quantity 366 

Color and Transparency of the Urine in Disease 368 

The Specific Gravity of the Urine in Disease 372 

Reaction of Urine in Disease 372 

Pathological Odor of the Urine 373 

Urinary Sediments 374 

Sediments of Organic Bodies, or Direct Products of These 375 

Inorganic Sediments 385 

Examination of the Urinary Constituents in Solution 391 

1. Anomalies in the Quantity of the Normal Constituents . 391 

2. Abnormal Constituents 393 

Albumin 393 

Bile-pigments and Bile-acids 400 

Other Soluble Constituents of the Urine 406 

The Urine as Afifected by Medicines and Poisons 410 

Examination of the Secretions of the Male Genito-urinary Apparatus 411 



CHAPTER VIII. 
Examination of the Nervous System. 

Preliminary Remarks on x-Vnatomy and Normal and Pathological Physiology 416 

1. The Motor Tracts and Centers 416 

2. The Sensitive or Centripetal Tracts • • 419 

3. Centers and Tracts of the Special Senses • • 420 

4. Remarks upon the Vessels Supplying the Brain 421 

5. Topographical Diagnosis of Diseases of the Brain and Spinal Cord 423 

Localization of Disease in the Spinal Cord 427 

Method of Examination 430 

Examination of the Seat of Disease 430 

The Skull 43° 

The Spinal Column 434 

The Peripheral Nerves and their Surroundings 435 

Examination of the Condition of the Mind 436 

Disturbances of Sensibility 439 

I. Sensitiveness to Peripheral Irritation 439 

{a) Cutaneous Sensibility 439 

(b) Deep Sensibility 444 

The Knowledge of Form (Stereognosis) 446 



CONTENTS. 1 5 

PAGE 

2. Sensiole Phenomena of Irritation and Pain from Pressure upon Nerves .... 446 

1. Paraesthesia 446 

2. Spontaneous Pain 446 

Distribution of the Sensory Cutaneous Nerves 448 

1. The Nerves of the Head 448 

2. Nerves of the Neck and Trunk 449 

3. Nerves of the Shoulder, Arm, and Hand 449 

4. Nerves of the Lower Extremity 451 

Disturbances of Motility 452 

1. Paralysis 452 

2. Disturbances of the Nutrition and Tone of Muscles 453 

3. The Reflexes 457 

1. Skin Reflexes 457 

2. Tendon Reflexes (Periosteal, Fascial, Reflex) 458 

4. Electrical Examination of the Nerves and Muscles , 462 

Regarding the Physics, and the Instruments Employed 462 

Methods of Examination in General and their Physiological Results upon the 

Living Human Body 466 

General Methods, and Explanation of the Terms Employed in Galvanic Ex- 
aminations 467 

Method of Examination in Detail. Normal Condition 469 

1. Points of Stimulation 469 

2. Method of Conducting the Examination 473 

(a) Faradic Examination 473 

{b) Galvanic Examination 475 

3. What to Observe in Determining the Electrical Reaction 476 

{a) Quantitative Excitability 476 

{b) Qualitative Irritability of Muscles from Galvanic Stimulation . . 478 

1. Reaction of Degeneration (RD) 478 

2. Myotonic Reaction 483 

3. Diagnostic Value of the Electrical Condition 484 

{a) Significance of Reaction of Degeneration 484 

{b) Significance of Diminished Irritability 484 

{c) Significance of Increased Irritability 485 

5. Mechanical Excitability of Muscles and Nerves 485 

6. Co-ordination and Ataxia 486 

7. Spasms of the Voluntary Muscles 488 

8. Voluntary Muscles, their Innervation, their Function, and the Diseases that Dis- 

turb Them 492 

1. Muscles of the Eye 492 

2. Muscles of the Face 492 

3. Muscles of Mastication, Tongue, Soft Palate 493 

4. Laryngeal Muscles 494 

5. Muscles of the Throat and Neck 495 

6. Muscles of the Trunk 495 

7. Muscles of the Thorax, Diaphragm, and Abdomen 496 

8. Muscles of the Upper Extremity 496 

9. Muscles of the Lower Extremity 500 

Disturbances of Speech (Lalopathy) 502 

I. Dysarthria and Anarthria 5^2 

II. Aphasic Disturbances, Disturbance of Graphic Communication (of Mimick- 
ing and Singing) 5^3 



1 6 CONTENTS. 

PAGE 

Mode of Procedure in Testing for Aphasic Disturbances 509 

Sense Organs 513 

The Eye 513 

1. Movements of the Eye 514 

2. The Pupils 517 

3. Sharpness of Vision, the Color-sense, and the Field of Vision 519 

Hearing 522 

Taste 524 

Disturbances of the Vegetative System in Nervous Diseases 525 

1. General Phenomena 525 

2. Disturbances of the Respiratory Apparatus 525 

3. Disturbances in the Circulatory Apparatus . 526 

4. Disturbances of the Digestive Apparatus „ 526 

5. Disturbances of the Urinary Apparatus 528 

6. Disturbances of the Genital Apparatus 529 

7. Disturbances of the Skin 529 

8. Bones and Joints 530 

Remarks upon The Diagnostic Value of the Symptoms in Nervous Diseases 531 



APPENDIX. 

1. Laryngoscopy 535 

2. Rhinoscopy ,. . 543 

3. Otosocopy 545 

4. Ophthalmoscopy 546 

5. Bacteria which come under Consideration in the Diagnosis of Internal Diseases . . . 548 

Index 555 



MEDICAL DIAGNOSIS. 



PART I. 

CHAPTER I. 

INTRODUCTION. 

The physician arrives at an opinion regarding his patient in two 
ways : by inquiry of the patient or of friends of the patient, and by 
his own objective examination. The result of the former is called the 
Anamnesis ; the latter reveals the Present Condition of the Patient. 
The notes which the physician makes from time to time in the course 
of his continued observation of the patient, and in which he records 
the changing phenomena of the disease, constitute the History of the 
Case. 

The judgment thus formed is briefly expressed as the diagnosis. 
In many cases this is pathologico-anatomical, since in a functional dis- 
ease it assigns the case to one of the schemata which are used for this 
class of cases. Only in one part of the terms usually employed in 
specifying the diagnosis something is comprised which nowadays is 
of supreme interest — etiology ; and at the present day medical science 
more and more seeks to establish an etiological diagnosis. Yet we 
know that many anatomico-pathological changes have very different 
causes, as, for example, diphtheritic disease of the mucous membrane, 
lobar pneumonia. This is also true of many functional diseases. 

In making a clinical diagnosis, therefore, one must aim to have it 
comprise not only the anatomical or purely functional characterization 
of the disease, but that it should also include a statement of its etiology, 
if the present state of our knowledge in this direction enables us to 
do so. 

But, furthermore, there belongs very much more to the conception 
of a diagnosis in its wider sense. Every person is individualized ac- 
cording to his physical development and his vital functions, but still 
more by the reaction of his tissues and his bodily functions to abnor- 
mal irritation. Hence every disease, according as it develops in this or 
that person, manifests a different, an individual, character. This fact is 
frequently observed, as in two cases of typhoid fever or two cases of 
pulmonary tuberculosis occurring in subjects apparently exactly alike, 

2 17 



1 8 MEDICAL DIAGNOSIS. 

in whom sometimes at the same stage of the disease there may be the 
greatest possible difference in the cHnical picture. But very frequently, 
in order to ascertain how the disease manifests itself in an individual 
case, it is necessary to make a most careful general examination of the 
patient, to analyze the secretions and excretions, and often even to 
extend the observations over a considerable period of time. 

The objective point of the physician's investigations at the bedside 
is therefore an vidividual diagnosis, first on purely scientific grounds, 
but still more important from the practical consideration that it must 
form the indispensable basis for individualizing the treatment. 

In recent times we have learned a great many new facts regarding 
the etiology of diseases, and especially of those that are infectious. At 
the present time a number of the most important etiological diagnoses 
are made by microscopical and bacteriological means. Herein consists 
an extraordinary advance in clinical instruction. But in respect to 
what has been said above here lurks a certain danger. That is to say, 
in itself an etiological diagnosis is always schematic : for example, it is 
positively asserted that the exciting cause of a lung-disease is the 
tubercle bacillus, but this says nothing of the disease, tuberculous 
phthisis, which is present. In order to discover this the patient must 
be carefully examined from head to foot, and it must also be deter- 
mined, partly by the anamnesis, partly by medical observation of the 
condition of the bodily functions and the variations in temperature. 
Formerly, before the tubercle bacillus was discovered, it was at least 
necessary to make a careful examination of the chest, perhaps also 
observations of the temperature, in order to make a diagnosis of tuber- 
culosis. Thus, in a sense, one was compelled to give attention to the 
form of the existing disease. But nowadays it suffices for many, un- 
fortunately, to find the bacilli in the sputum. This example serves to 
show how easy it is for the interest of the physician to be diverted from 
the patient himself by his investigations with the microscope and in the 
bacteriological laboratory. Every one who shares with me the opinion 
that it is necessary to make an individual diagnosis will take cogni- 
zance of the fact that clinical thinking may be neglected in the pursuit 
of these newer methods. The individual diagnosis can never be made 
at the study-table, but only and always at the bedside, and there only 
by a sort of artistic construction of the complete picture of the disease 
out of its collective phenomena, anatomical and functional. 

Hence what was expressed in the Preface to the fir.st edition of this 
work must here be repeated in the most emphatic terms : we should 
guard ourselves against the mistake of theorizing. A clinical diagnosis 
must always take into consideration the wliole man. The clinician 
must never be satisfied with a diagnosis made with a microscope or a 
chemical reaction. All the phenomena must always be combined in a 
comprehensive description. 

Since the chief object of this work is the teaching of the examina- 
tion of patients and the presentation of the methods of conducting it, 
we limit ourselves to a short description of the method of obtaining the 
anamnesis. 



INTR OD UCTION. 1 9 

ANAMNESIS. 

What is it necessary for the physician to know, beyond what his 
examination reveals, in order to recognize a given disease in itself and 
to form a critical judgment regarding the patient in a larger sense? 
It is difficult to define this. Facts which appear insignificant in them- 
selves, in experience pften exercise a decided influence upon the special 
diagnosis, and especially in forming a judgment regarding the consti- 
tution of the patient or upon the timely recognition of a secondary dis- 
ease. From having at hand clear knowledge of the symptoms of the 
different diseases, both of their remote or predisposing and of their 
directly exciting causes, a physician of experience is able in a short 
time to select what is essential from the past, and so to avoid too great 
prolixity. But it is always well for the beginner to secure as complete 
an anamnesis, or prior history, as possible, in order that he may allow 
nothing of importance to escape his attention. 

The anamnesis generally begins with and involves the question as 
to whether the disease is acute or chronic, what organs are affected or 
are inclined to be diseased. This determines the examination to fol- 
low, in that certain organs are examined with greater exactitude than 
others. But the examiner must guard himself from too great influence 
or prejudice from the result of the anamnesis: the objectivity of the 
objective examination must be kept in view ; and this, in turn, may 
give occasion for supplementing the anamnesis by propounding addi- 
tional inquiries regarding certain occurrences and appearances, and 
thus a conclusion is finally reached. It is advisable for the student, 
under all circumstances, with all the patients he examines, and for the 
physician at least with his more important cases, to note down in 
regular order the results both of the anamnesis and of his examination. 
[See Translator's note, page 24 et se^.~\ 

For the purpose of clinical instruction it is frequently of advantage 
to note the present state of the patient before making the anamnesis. 
We are thus better able to see the real facts and to preserve the objec- 
tivity of our judgment ; but it cannot be expected that a physician will 
long continue to observe this rule in ordinary practice. 

Mode of Taking the Anamnesis. — First, we always note the 
name, occupation, age, residence of the patient. Then we conduct, as 
simply as possible, a dialogue with the patient, or, in the case of a 
child or of a person who is insensible, unconscious, or mentally dis- 
turbed, with his neighbors or relatives. How much we may allow 
the person simply to tell, how much we must learn by asking ques- 
tions, must depend upon the cultivation and intelligence of the one 
giving the information. We must particularly guard against asking the 
patient leading questions — that is, influencing the reply by the manner 
in which we put the questions. To the question : '* Have you, then, 
really never had any pain in the bowels ? " or, " Did you never have 
any pain in the bowels ? " we shall almost certainly receive an affirma- 
tive answer, either from indifference, or from a desire to make his com- 
plaints as interesting as possible and to enlarge upon them, or, lastly, 
because he is of a very impressionable nature, and the question of 
pain suggests to him what in reality he has not had. 



20 MEDICAL DIAGNOSIS. 

On the other hand, we must exercise close scrutiny of what the 
patient voluntarily communicates — a scrutiny which it is generally best 
not to allow the patient to know of. Where and how this has to be 
done can of course not be explained at length. We will here note 
only a few points which occur frequently : 

ia) We must not accept without further inquiry the name the 
patient gives to a disease he has formerly passed through, since mis- 
chief is often done by the laity in the use of the names of diseases, as 
of diphtheria, typhus, etc. In any doubtful case we inquire its symp- 
toms, and also what the physician who attended the patient had called 
the disease. 

{6) The simulation of a disease is common. This was formerly 
confined in large part to the domain of hysteria ; but, nowadays, from 
certain known social reasons, it is much more frequent. Neuralgia, 
rheumatism, trembling, spasms, even paralyses, the principal symptoms 
of traumatic neuroses, also pains in the bowels, asthmatic attacks, are 
the conditions which are most often simulated. In this way the phy- 
sician may be led astray not only by false anamnestic statements, but 
clever persons are often capable of doing incredible things in simulating 
objective symptoms. 

[c) The concealment of the existence of disease is manifest with 
reference to the different sexual diseases, especially syphilis. Women, 
moreover, often attempt to avoid all statements in regard to the sexual 
apparatus, even when it alone is diseased. Inebriates and those who 
practise onanism often confess their habits to the physician only with 
great reluctance. 

What the Anamnesis Comprises. — The exact knowledge of 
the etiology and symptomatology of internal diseases is here the only 
correct guide, and at the same time gives us complete information re- 
specting the cases which, under various circumstances, come under 
consideration. We are content with indicating the essential point of 
view by the introduction of a few examples. We may divide every 
anamnesis into the following two parts : 

I. Previous liistory of the patient : This comprises all that it is im- 
portant to know up to the beginning of the disease on account of which 
the patient consults the physician. 

II. The present disease : This relates to the exciting causes, the 
commencement, and the course to the present time. 

Here it is always necessary to ascertain exactly how deeply the 
present disease is rooted in the former history of the patient. That is 
to say, it is not only necessary to consider the first vestiges of the 
present diseasi; itself, but also those morbid conditions which have 
prepared the soil for it. 

Previous History of the Patient. 

I. Hereditary Disease [Heredity). — This is of importance in so many 
diseases that in each and every case we have to inquire regarding the 
parents, brothers, and sisters of the patient, and also very often regard- 
ing the brothers, sisters, and parents of the parents. There especially 
come into view in this connection syphilis, tuberculosis, diseases of the 



INTR on UCTION. 2 1 

brain, and certain general neuroses. Heredity as regards rheumatism, 
carcinoma, diseases of the heart, and gout is of secondary importance, 
yet not immaterial. These diseases are in part inherited as such, in 
part they confer upon the descendants only the organic foundation, the 
disposition to the new development of the same or related diseases. 
Different descendants are variously divided by heredity. Often indi- 
viduals, or a majority, are wholly exempt. It also happens that one 
generation is entirely passed over, and the trouble reappears in the 
following generation (hence the question regarding the grandparents). 

It has been proved that most of the infectious diseases can be trans- 
mitted from mother to child in utero. This is true of syphilis, although 
the conditions are more complicated in this disease. Tuberculosis, as 
such, is only exceptionally transmitted. 

2. The manner of life, habits, profession, occupation, residence, expe- 
riences as to fatigue, other harmful influences to which they have been 
exposed, whether they have descenda^its, and, in the case of women, the 
number and character of their confinements, compose this group. 

Under tJie manner of life are considered the diet, character of dwell- 
ing, and the clothing. Injurious habits play a very important part in 
the manner of life, especially immoderate use of alcohol and other 
luxuries, of tobacco, narcotics, etc. ; venereal excesses must also be 
taken into account. But it is important to remember that, within wide 
limits, the harm of these things differs with the individual. 

Profession and occupation on the one hand affect the whole constitu- 
tion, and on the other are often to be regarded as predisposing or 
exciting causes of disease ; finally, they may exert a favorable or an 
unfavorable influence upon the course of an existing chronic disease. 
Thus, for instance, stonecutters and polishers, millers, workers in wool, 
by continually inhaling fine dust from the stone, flour, and wool, are 
very frequently inclined to bronchial attacks and diseases of the lungs ; 
thus, too, the occupations that have to do with lead (type-setting, type- 
polishing, painting, etc) or with mercury (making mirrors, etc.) fre- 
quently cause chronic poisoning by these metals. Persons who are 
engaged about sheep, swine, horses, or with the fresh skins and hair of 
these animals, are apt to have malignant pustule and other diseases. 
Phthisical patients are specially to avoid working as stonecutters, 
while victims of heart-disease are not to be employed with lead ; and 
so of other diseases and occupations. 

The place of prior residence is to be considered with reference to 
miasmatic (intermittent) endemic diseases or epidemics, which may 
have prevailed there at that time. With travellers, exotic diseases, 
which less frequently occur in their native places, as lepra, some infec- 
tious diseases, certain exotic animal parasites, etc., must be thought of. 

As x^<gd,x6i^ fatigue , army marches are to be regarded as particularly 
fruitful sources of disease. At the present time it is becoming more 
and more necessary to take into account those voluntary exertions 
which are connected with sport. A fall, slight perhaps, but whose 
effects continue ; or a wound, without other immediate sequelae except 
that it does not heal, — of these account must be taken, and also of very 
harmful momentary experiences, as sorrow, care, severe fright, anxiety. 

Where there is sterility we consider anomalies of the sexual appa- 



22 MEDICAL DIAGNOSIS. 

ratus of the man or woman, but especially the question of syphilis. 
The puerperal period, even when it does not pursue an unfavorable 
course, may in various ways be a source of disease. 

3. Diseases ivliieJi one has had — not only acute diseases, but the 
temporary outbreak of a chronic disease ending in apparent or real 
recovery. 

Certain acute diseases may have as sequelae certain other diseases 
which either are directly connected with them, as paralysis following 
diphtheria, nephritis after scarlet fever, or which appear after a shorter 
or longer period, as valvular disease of the heart from endocarditis in 
acute articular rheumatism, arising during scarlet fever. 

The 02itbreaks of a chronic disease are often spoken of by patients 
as diseases which they have gone through ; as, especially, the primary 
and secondary affections of syphiHs, temiporary manifestations of tuber- 
culosis of the lungs, etc. 

Some acute diseases are not prone to attack a person a second time. 
This is true of scarlet fever, measles, and typhoid fever. [But it is not 
uncommon for a person to have measles two, three, or even four times, 
and a second attack of typhoid fever is occasionally met with.] Cer- 
tain other diseases, however, are liable to befall a person again, either 
because they leave behind a general disposition, the nature of which 
we do not understand, or because they produce some chronic local 
changes which give occasion for a new attack of the disease (erysip- 
elas, malaria, pneumonia, articular rheumatism, appendicitis, and peri- 
typhlitis). Certain diseases of childhood are especially to be considered 
— for example, scrofulosis as early indication of tuberculosis ; mani- 
festations of hereditary syphilis ; frequent convulsions as an early sign 
of anomalous condition of the nervous system. The diseases ordinarily 
designated as " children's diseases " generally have no significance as 
to the future, but yet sometimes, unfortunately, they leave lasting 
suffering behind them, as emphysema after whooping-cough, etc. 

The Present Disease. 

1. The possible exciting causes must be first considered. It is espe- 
cially important for the early diagnosis of an infectious disease to in- 
quire whether the patient has been exposed to infection. Many diseases 
are conveyed by a very short exposure ; others require a longer exposure 
or even a personal contact. Also the period of incubation must be con- 
sidered. This is the period from the moment of infection until the 
outbreak of the disease. With most transferable diseases this period is 
of a known, somewhat exactly defined, duration. Moreover, "taking 
cold," over-exertion, improper eating and drinking, taking of poison, 
etc. come under consideration. 

It is to be remarked that the laity often assume something as an 
exciting cause, thus especially " taking cold." 

2. The first appearances and the course of the disease up to the time 
of examination. 

With chronic diseases the first appearances are sometimes, at the 
beginning, scarcely noticeable: they often consist only -in a change 
from the previous behavior, unless the new condition in itself directly 



INTR OD UC riON. 2 5 

appears to be one of disease : a person who previously had red cheeks 
becomes paler (all kinds of wasting diseases), a stout person without 
other reason becomes thin, one who always previously ate and drank 
little all at once eats and drinks considerably (diabetes), a person 
formerly very orderly becomes disorderly, forgetful (disease of the 
brain, especially progressive paralysis), etc. Even when they have 
made considerable progress, such gradually developing disturbances 
often are not at all noticed by ignorant and indifferent people. 



CHAPTER II. 
EXAMINATION OF PATIENTS. 

The examination of the patient comprises — 

1. A ge7ieral examination, which takes into account certain phe- 
nomena of disease which concern the organism as a whole and are the 
expression of a pathological change of the whole organism. 

2. A special examination, which inquires into the different regions 
and organs, the secretions and excretions of the body. At the bed- 
side we generally proceed in such a way that, beginning at the head, 
we gradually go downward, in order to facilitate the investigation by 
examining contiguous organs. But in many cases it is better to group 
together organs that are functionally related, no matter what their 
anatomical location may be, since we thus quickly obtain a compre- 
hensive view of the way in which the affected organs or systems are 
disturbed. Thus, in diseases of the heart, the heart and blood-vessels, 
in diseases of the nervous system, the central and different peripheral 
organs, are examined together. Sometimes, as in the case of very weak 
or very unruly patients, as children, the examination of the body must 
be very brief Here the expertness of the physician especially is put 
to the test to the utmost degree. 

It will best answer the purposes of study if the division of the sub- 
ject throughout strictly conforms to the organ-systems, and hence the 
special part is divided into — 

I. Examination of the respiratory apparatus. 
II. Examination of the circulatory apparatus. 

III. Examination of the digestive apparatus. 

IV. Examination of the urinary apparatus, including also in part 

the sexual apparatus. 
V. Examination of the nervous system. 
Examination with the speculum and bacteriological diagnosis are 
discussed in the Appendix. 

NOTE BY THE TRANSLATOR UPON KEEPING RECORDS OF CASES, AND 
A FORM FOR RECORDING THE RESULTS OF A MEDICAL EXAMI- 
NATION. 

It is not practicable at the bedside to go through any set form for 
conducting the inquiry regarding the present illness. The most direct 
way of getting at it, and the one that will lead to the most satisfactory 
replies to our interrogatories, is to ask the question. What is your 
complaint ? How are you sick ? or some such direct question as this. 
In this way we get at once at the disease we are called upon first to 
diagnose and then to treat. As we proceed we will arrange the facts 

24 



EXAMINATION OF PATIENTS. 25 

in our minds, and when we make the record we shall place them in a 

natural and logical order. Having a regular form for keeping records 

of cases soon develops an order of procedure in accordance with it. 

Case-taking is a most valuable aid to the student in clinical study. 

1. He learns to make a systematic examination of the patients he 
sees. He forms the habit of bringing before his mind each factor in 
the case in orderly succession. There are two advantages from this : 
First. He forms the habit of thoroughness in examining his cases. 
Second. He can readily compare one case with another, having ar- 
ranged the factors of each in like order. While it is not necessary in 
making the examination to have or to follow strictly a printed form, 
yet it is desirable to have some regular form for making the record, so 
that cases that are similar can be readily compared. One case may 
require going over only a few points ; in another it will be necessary to 
examine every organ in the body. 

2. The memory is greatly strengthened. Memory depends upon 
attention and repetition. Case-taking cultivates both of these in an 
eminent degree. Facts and symptoms that else would escape notice 
entirely or be only slightly noted are brought prominently before the 
mind for consideration. Their value or bearing is weighed, and so 
they are strongly impressed upon the mind. 

3. The mind is developed by this habit of carefully reflecting upon 
every feature of a case. Thought is both stimulated and made easy. 
Clearness and power of thought are increased. Independence of 
judgment is cultivated. Both knowledge and intellectual cultivation 
are acquired. *' By knowledge is understood the mere possession of 
truths ; by intellectual cultivation or intellectual developjnent, the power 
acquired by exercise of the higher faculties, of a more varied, vigorous, 
and protracted activity " (Sir William Hamilton). 

4. Ease and habit of writing are almost unconsciously acquired. 
This is most valuable. The great majority of physicians keep no 
records of cases. Many never record or publish important ones, 
because they have not the facility of writing which comes with prac- 
tice. Anything is easy to the practised hand. " Who can estimate how 
much we have lost from the fact that generations of men gifted with 
powers of acute and shrewd observation have passed away without 
leaving one record behind them? Think not that it is the hospital 
physician or surgeon alone who can advance the progress of medicine. 
There is not a practitioner who could not aid this great work. But he 
can only add to it with efficiency if he has faithfidly recorded his obser- 
vations, and does not trust to the general and vague impressions of 
unassisted memory. Therefore, on all grounds, personal to yourselves 
and general for medical science, so engrain this habit within you that it 
becomes a second nature " (Coupland). 



26 MEDICAL DIAGNOSIS. 

THE ANAMNESIS. 

Personal and Previous History. 

Name, Address, 

Birthplace, Age, Sex, 

Family history — Heredity : 

Father, 

Mother, 

Brothers, 

Sisters, 

Other relatives. 
Manner of life, habits, occupation, residence, etc. 
Previous diseases — character and results. 

(Note each one that was of such a character as to have any lasting 
effect upon the health or vitality.) 

Present Illness. 
Duration, 

Possible exciting cause. 

How began — suddenly or not; prodromal symptoms, 
Course of the disease till the time of examination. 

Examination of the Patient. 

General examination : 
Appearance, 
Psychical condition. 
Position in bed. 
Structure and nutrition. 
Skin and subcutaneous tissues, 
Temperature, 
Pulse. 

This covers the general features of every case. Attention has been 
directed, by what has been learned thus far, to some one or more of 
the special organs or systems of the body, It is usually best first to 
examine that, and to make this examination very full and thorough. 
Then the remaining organs of the body can be examined with greater 
or less fulness according as they are found to be affected by the prin- 
cipal disease or as they are related to the one specially diseased. It is 
well to form the habit of following a certain order in examining each 
organ. One is much less apt to overlook any part ; and, too, as has 
already been pointed out, the records will be more easily consulted 
and compared. For this purpose it is well to take the order of the 
text-book, so as to become thoroughly familiar with each subject. It 
is not of so much importance that this or that one be adopted, pro- 
vided it is a good one. But we have here a notable illustration of the 
truth and value of the Spanish proverb : " Beware of the man of one 
book." 

Presuming that those who use this work will follow the order laid 
down in it, the form now given conforms to the order in which the 
systems are treated. 



EXAMINATION OF PATIENTS. 2/ 

SPECIAL EXAMINATION. 

Examination of the respiratory apparatus : 

Nose, 

Larynx. 
Examination of the lungs : 

Inspection of thorax, 

Palpation of thorax, 

Percussion of thorax. 

Auscultation of lungs, 

Auscultation of voice. 

Measurement of thorax, 

Cough and expectoration. 
Examination of circulatory apparatus : 

Inspection and palpation of the region of the heart, 

Percussion of the heart, Apex-beat, 

Auscultation of heart, 

Examination of the arteries and veins, 

Examination of the blood. 
Examination of the digestive apparatus : 

Mouth, gums, and pharynx, 

Esophagus, 

Stomach, 

Intestines, 

Peritoneum, 

Liver, 

Spleen, 

Pancreas, omentum, retroperitoneal glands. 

Contents of the stomach and vomited matters, 

Process of digestion. 

Feces. 
Examination of the urinary apparatus : 

Kidneys, 

Ureters and bladder. 
Examination of the urine : 

Amount in twenty-four hours, 

Reaction, Odor, 

Specific gravity. 

Sediment, 

Albumin, 

Blood, 

Bile, 

Sugar, 

Other constituents. 
Examination of secretions of the male sexual apparatus. 
Examination of the nervous system : 

Disturbances of sensibility. 

Motor disturbances, 

Disturbances of speech, 

Organs of special sense. 



PART II. 

CHAPTER III. 

GENERAL EXAMINATION. 

This consists of a number of subordinate divisions — namely, we 
have to consider — 

L The psychical condition of the patient. 
II. The position in bed, attitude, posture. 

III. The general structure of the body and the nutrition. 

IV. The skin and the subcutaneous cellular tissue. 
V. The temperature and the pulse. 

I. THE PSYCHICAL CONDITION OF THE PATIENT. 

From this — that is, from the clearness of his intelligence, his sus- 
ceptibility to external impressions, his power of thought, from the pos- 
sible presence of depression or irritability — we may often obtain im- 
portant points of diagnosis, both for diagnosis in the narrower sense, 
certain diseases being accompanied with definite manifestations of this 
kind, and for diagnosis in a broader sense — that is, to form an exact 
opinion of the present disease — since the severity of a disease, the pos- 
sible turn for better or worse, often becomes manifest by the psychical 
condition of the patient.^ 

II. THE POSITION OF THE PATIENT, ATTITUDE, POSTURE. 

The position and attitude of the patient furnish a very simple aid to 
diagnosis, because generally they can be determined by a single glance 
of the eye. From them conclusions in various directions may be 
drawn. People in health or only slightly sick usually assume the 
dorsal position or a position upon one side in a certain unconstrained, 
comfortable position (the active dorsal or side position). On the con- 
trary, patients who either are not wholly conscious, or who have 
become very weak, frequently are inclined to slide down toward the 
foot of the bed and sink into a heap there — a position which manifests 
weakness, and in some respects, but especially for breathing, is very 
unfavorable (the passive dorsal and side position). 

In acute infectious diseases, more than elsewhere, the passive dorsal 
position is specially noteworthy. It is particularly so when apathy 
and clouded intelligence are combined with great muscular weakness, 

^ Regarding this and the way in which the examination in this direction is conducted, 
see the section on Examination of the Nervous System. 

28 



GENERAL EXAMINATION. 29 

as is frequently the case in typhoid fever, where such a condition of 
the patient is so frequently and sometimes early present that it may 
aid in the diagnosis. 

But in still another way tJie position in bed is sometimes charac- 
teristic. Patients with acute affections of the chest-organs involving 
only one side (pneumonia, pleurisy, pneumothorax) generally lie upon 
the side, and for the most part upon the side affected. This may be due 
to various causes. The pain caused by breathing is generally in this 
way diminished, because by lying upon the side the motion of that 
side is very much lessened, while, on the other hand, the motion of 
the upper side in breathing is greater when on the side than when the 
patient lies upon the back ; hence the sound side, when the patient lies 
upon the diseased side, can better compensate for the loss of the por- 
tion diseased. In exudative pleuritis frequently there is the further 
advantage in lying upon the affected side that the exudation least 
interferes by pressure with the healthy side. 

Yet patients with pneumonia not infrequently lie upon the healthy 
side because they are not able to endure the pressure of the weight of 
the body upon the diseased side. That in diseases of the chest pa- 
tients are generally inclined at the beginning of the disease to he upon 
the sound side, and later upon the diseased side, I am not able to 
affirm. 

Children sick with typhoid fever sometimes lie on one side with the 
legs drawn high up (position of a hunting dog). Such patients, being 
often at the same time in stupor or unconscious, continually return to 
this position. It seems like an unconscious impulse, and at the same 
time has something of the so-called compulsory position. 

Difficidt breathing {dyspnea), if extreme, prompts one to assume the 
upright sitting posture in bed or in an easy-chair — orthopnea — because 
in this attitude the action of the accessory muscles of respiration is 
more effective than when lying down. Orthopnea may therefore occur 
with all diseases which are accompanied with marked interference with 
respiration, as in narrowing of the air-passages in disease of the lungs 
(comparatively rare with phthisis),^ in diseases of the pleura, heart, peri- 
cardium, with large effusions into the abdominal cavity which press the 
diaphragm up, and in general dropsy with effusions into the cavities 
of the body. In the severest cases the patients may indeed be obliged 
to keep the sitting posture, even to sleep. The continued exertion of 
sitting and the diminished sleep obtained in this position, besides the 
great anxiety and excitement these patients generally have, usually 
quickly bring on exhaustion. 

Another group of characteristic situations and positions in bed refer 
to diseases of the brain and its membranes. Thus meningitis betrays 
itself often at the first glance by opisthotonos, with the head boring 
into the pillow — so-called contraction of the neck. In circumscribed 
disease of the cerebrum the head is sometimes persistently inclined to 
be drawn forcibly to one side — forcible contraction of the head. In 
affections of the cerebellum and of the pediculi cerebelli medii the 
patient sometimes continually keeps a certain lateral position as by an 
unconscious or only half-conscious impulse. If the patient is moved 

^ See under Dyspnea. 



30 MEDICAL DIAGNOSIS. 

out of this position, he always returns to it again immediately. Such 
positions are called compulsory positions. It is well to use this ex- 
pression exclusively for those attitudes and positions which the patient 
takes or remains in instinctively when there is complete exclusion of 
consciousness. But the positions of patients suffering from disease of 
the chest, etc., mentioned above, do not strictly belong to the compul- 
sory positions. 

Paralyses and atrophies of the most different muscles, particularly 
those of the trunk, of course furnish a great number of anomahes.' 
There is a sign which belongs to the most varied chronic inflammatory 
abdominal affections which involve the peritoneum : sometimes patients 
have a peculiar bent-forward attitude in standing and walking, because 
in an upright attitude they feel tension in the abdomen. Here belong 
parametritis, more severe chronic perityphlitis, etc. 

III. THE STRUCTURE OF THE BODY AND NUTRITION: 

WEIGHT. 

The development of the skeleton determines the form of the body. 
Generally, firm bones and broad, flat chest are characteristics of strong 
and enduring health, while those persons of dehcate skeleton, espe- 
cially with slender ribs and narrow chests, are considered capable of 
both limited life and endurance. Yet this is only a general rule. We 
often see people of delicate build who are remarkably tough and en- 
during, both with reference to exertion and disease ; and not infre- 
quently we find robust people with little power of resistance, especially 
to acute diseases. 

Unusically defective development of the skeleton, also other anomalies 
of the growth of the skeleton similar to rhachitis (among others " the 
fetal rhachitis "), are frequently found in idiots and cretins. There is 
also the development known as dwarf, without any other anomaly. 

The form of the thorax is of especial importance. With a slight 
and narrow chest-cavity there is a proportionally frequent disposition 
to tuberculosis of the lungs ; and, on the other hand, a certain fulness 
carries with it a tendency to emphysema of the lungs.^ 

The significance of the structure of the pelvis is manifest in the 
practice of obstetrics. 

The muscles, the subcutaneous tissues, and the skin furnish a 
means of judging of the nutrition and also of the weight. In general, 
well-nourished and healthy persons have a certain volume and firm- 
ness of muscles. There is also a relation between the muscles and 
the skeleton. But even in perfectly normal persons there is a very 
marked difference in the volume of the muscles, which is not always 
explained by differences of occupation. By experience the eye grad- 
ually becomes quick in recognizing a suspiciously small muscular 
volume ; yet the firmness of the muscles is a better guide to an opinion 
than their volume. 

The fat of the subcutaneous tissues may be very differently de- 
veloped in persons of good health. As a rule, it varies with the age, 

^ See section on Nervous System. 

''■ This will be more particularly spoken of under Respiratory Organs. 



GENERAL EXAMINATION. 3 1 

being greater for the first years of life up to the forty-fifth or fiftieth 
year. Beyond this it again, as a rule, becomes less. It also sometimes 
varies in a shorter time without being caused by disease, most fre- 
quently and markedly in women at about twenty years of age. It 
varies also, as a matter of course, with the kind and the richness of 
food, as well as with the occupation. Loose adipose tissue generally 
indicates a weak organization. 

A marked degree of leanness of the subcutaneous tissue under 
all circumstances is suspicious, and suggests an examination as to 
whether it may be caused by disease. In the same way the accumula- 
tion of fat beyond a certain degree becomes pathological. The 
measure or degree can only be established by experience. 

Of much greater importance is a commencing, even though a slight, 
wasting away of the subcutaneous fat, and eventually also of the mus- 
cles. As we have said, this is sometimes physiological. It can also 
take place from very poor nourishment, as among the poorer classes. 
But in the majority of cases it is caused by disease, and it is therefore 
important not to overlook it. This wasting can only really be learned 
by the physician when he has known the patient for some time. When 
this is not the case he must rely upon the statements of the patient and 
his surroundings, and therefore this subject properly belongs to the 
** previous history." When the emaciation is marked, its proof is 
furnished by the condition of the skin. In these cases the skin 
of the patient's whole body is loose, and can easily be taken up in 
folds. 

Excessive wasting is denominated atrophy, emaciation, and, when 
this is accompanied by general loss of strength and failure of function, 
marasmus or cachexia. 

Weight. — The weight of the body is an excellent index, and one 
which is superior to all other signs of corpulence and its increase or 
diminution. The absolute value of the weight of the body in the dif- 
ferent periods of life has no diagnostic interest, for the reason that it 
varies within wide limits. Likewise the relation of the weight of the 
body to the height and the circumference of the chest has scarcely any 
significance for our purposes, because as yet a norm has not been 
determined. On the other hand, change in the body-weight wrought 
by disease is of the greatest importance. In chronic diseases this is an 
extremely valuable means of determining whether the disease is in- 
creasing, standing still, or is being recovered from. Taking the weight 
regularly (say, weekly) in cases of tuberculosis is especially to be rec- 
ommended, also in diseases of the digestive apparatus. In convales- 
cence from acute diseases, following the weight of the body is also a 
very important aid, especially for the early recognition of the possibility 
of the disease becoming chronic or of the presence of associated chronic 
diseases. 

Edema influences the weight in a peculiar manner. It causes a 
misleading increase in weight when it makes its appearance, and a by 
no means disagreeable decrease of the weight of the patient when it 
disappears. It is important in diseases which dispose to dropsy to 
always think of its possibility whenever striking alterations of weight 
appear, even in cases where edema or effusion cannot be demonstrated, 



32 MEDICAL DIAGNOSIS. 

because the lesser degrees of anasarca generally elude exact clinical 
demonstration. 

According to Bornhardt/ the relation of the weight of the body, P, 
to the height, H (in cm.), and to the average circumference of the chest, 
C (measured at the level of the nipples, in cm.), for the average indi- 
vidual, may be reckoned as follows : 

P = I kilos^rams. 

\240/ 

The weight of the body of the newly-born and its increase during 
the first months is of special significance.^ 

Diseases of the alimentary tract and all febrile diseases, whether 
acute or chronic (of the latter especially tuberculosis), also severe forms 
of diabetes mellitus, and, finally, all malignant growths, produce marked 
emaciation. But a certain degree of emaciation can be produced by 
any disease of an internal organ. 

IV. SKIN AND SUBCUTANEOUS CELLULAR TISSUE. 

In medical diagnosis the condition of the skin and subcutaneous 
tissue is considered with reference to the following points : 

A. The condition of general nutrition. 

B. The moisture of the skin ; perspiration. 

C. The color of the skin. 

D. Certain pathological appearances of general diagnostic value 

(characteristic eruptions, hemorrhages, scars, etc.). 

E. Edema. 

F. Emphysema of the skin. 

Skin-diseases proper and certain acute infectious diseases with 
special localization upon the skin (the so-called acute exanthematous 
diseases) are not considered in this work or only incidentally men- 
tioned. 

A. The State of Nutrition of the Skin. 

In extremely old age the skin over the whole body appears to be 
physiologically thinner, the subcuticular cellular tissues probably hav- 
ing the greatest share in this atrophy. In earlier years a noticeable 
general atrophy of the skin or the subcuticular cellular tissue exists 
only where there is a very severe cachexia. The skin is then thin and 
generally dry. It loses its tone, and when taken up in a fold resumes 
its place slowly. 

The different forms of circumscribed atrophy of the skin which 
have been described do not interest us here. They belong to works 
upon skin-diseases. 

B. The Moisture of the Skin; Perspiration. 

Physiology teaches us that the moisture of tlie skin, as well as the 
visible secretion of perspiration, is influenced by various circumstances. 

1 Cited by H. Vierordt. 

''■ Regarding this subject see works upon obstetrics and diseases of children, also Daien 
unci Tabellen, by H. Vierordt. 



GENERAL EXAMINATION. 33 

It is increased during active exertion by increased temperature of the 
blood, by moist heat, by mental impressions, especially fear ; finally, 
by certain ingesta, as hot tea, by pilocarpin, etc. In some of these 
cases there is at the same time an increase of heat of the body, which 
is overcome by the perspiration, cooling being caused by its evapora- 
tion. It is well known that the perspiration exercises a continual 
regulating influence on the temperature of the body. 

The loss of water by evaporation (the greater part of the insensible 
perspiration) in health is, cceteris paribus, greater at night than during 
the day. It seems to alternate with the secretion of the urine. 

In healthy people the secretion of perspiration is in this way very 
changeable. But it is still more so in cases of illness. It may be 
increased to such a degree that the whole bed may be wet through 
(Jiyperidrosis). On the other hand, it may be so diminished (Jiyplii- 
drosis) that the skin is perfectly dry {anidrosis). Hyperidrosis of the 
whole body is called Jiyperidrosis universalis ; if confined to a part of 
the body, hyperidrosis localis. The latter may be unilateral (Jiemi- 
drosis). 

The influences which produce these morbid alterations of perspira- 
tion are without doubt of different nature. In the first place, there are 
chemical influences by abnormal products in the blood and lymph, as, 
for instance, accumulation of carbonic acid ; of urinary products, as 
urea ; products of muscular exertion. Here also belong the auto- 
infections. Then there are bacterio-chemical bodies, and, lastly, other 
poisons, which produce or suppress perspiration. 

These factors in part act directly upon the sudorific glands, in part 
indirectly through the nervous system. The latter, however, may be 
acted upon by independent influences, giving rise to the following : psy- 
chical perspiration ; hyperidrosis and anidrosis in central and peripheral 
diseases of the nervous system. 

A general perspiration may take place in cases of illness — 

1. When there are present conditions which are analogous to those 
which produce it in persons in a state of health, as in cases of strong 
tetanic convulsions by the increased muscular work and heart-action. 
On the contrary, in cases of epileptic, hysterical, and other convul- 
sions we have either no perspiration, or at least none corresponding 
with the very great muscular exertion ; in all possible diseased con- 
ditions connected with great excitement, especially fear, or with severe 
pain ; and again, sometimes, not always,^ from a high degree of atmo- 
spheric heat, warm baths, moist warm pack, or sudorifics (pilocarpin, 
etc.). Morphin also, with some persons, induces perspiration. 

2. /;/ difficidt breathing — dyspnea. This is generally accompanied 
by sweating. In the same way sweating sometimes occurs wath 
heart-disease, accompanied by an engorged condition of the " greater " 
circulation ; also with all diseases of the respiratory organs and their 
surroundings which interfere with respiration. Perspiration is here 
produced both by the venous quality of the blood and the anxiety or 
fright ^ which is always present in dyspnea. 

3. hi febrile diseases. Sweating usually occurs with the fall of the 
temperature in these diseases. In these cases the perspiration performs 

1 See below under Anidrosis. ^ See above. 

3 



34 MEDICAL DIAGNOSIS. 

the additional service of washing away the poisons which have accumu- 
lated during the course of the disease. The most important instances 
are {a) the critical sweat of a rapid definite decline of the fever, espe- 
cially frequent in pneumonia and febris recurrens [relapsing fever] ; (^) 
the sweat which regularly accompanies the fall of temperature in inter- 
mittent fever and pyemia (diseases which manifest themselves by rapid 
rise and fall of temperature), the night-sweats of the hectic fever of 
phthisis, and the sweat of the remittent (hectic) fever of typhoid fever ; 
and (r) the cold sweat of collapse (that is, the sudden failure of strength 
in the death-struggle). 

Acute articular rlieiimatisni manifests itself by considerable poison- 
ous perspiration, which may not depend upon a fall of temperature ; 
this is also true in rachitis. Finally, there is always the inclination to 
perspiration in the commencement of convalescence from severe dis- 
eases and in parturient patients, when there is great weakness and the 
vascular system is easily excited. 

Local sweatmg occurs in various neuroses, also in organic diseases 
of the nervous system. There is very frequently sweating of the 
whole of one side {Jiemidrosis) or of the head alone, as in Baselow's 
disease, migraine, hysteria, localized disease of the brain, and in 
mental diseases. 

DimmisJied secretion of sweat, even to complete anidrosis, is ob- 
served chiefly in high continued fever. It is, moreover, a peculiarity 
of all diseases which are accompanied with considerable loss of water 
by the bowels or the kidneys, of severe diarrhea of any kind, con- 
tracted kidney, and diabetes. The anidrosis which exists with general 
dropsy, in consequence of the anemia of the skin produced by the 
pressure and stretching, has a peculiar appearance.^ 

The anidrosis of high fever and general dropsy is very persistent, 
sometimes resisting all therapeutic measures, as, for instance, those 
acting directly upon the skin (moist heat, etc.), and the medicines 
already mentioned. 

Qualitative alteratiojis of sweat exist sometimes in severe jaundice,^ 
when it contains the coloring matter of bile and is yellow in color ; 
also, when the urinary secretion is greatly diminished or entirely sup- 
pressed, as in nephritis, diseases of the urinary tract, and cholera. It 
then sometimes contains considerable quantities of urinary products, 
which in some cases, by the evaporation of the perspiration, crystallize 
upon the skin (especially upon the nose and forehead) in small white 
scales. This is called uridrosis, the scales giving the reaction of 
urinary ingredients. Occasionally, however, they consist only of 
common salt. 

C. The Color of the Skin. 

As is well known, races differ in the color of the skin, but even in 
the Indo-Germanic race there are variations depending upon the stock,, 
the climate (blond, brunette). In some nations the pale, in others a 
more florid, complexion, especially of the face, preponderates. We 
know that there are differences depending on the mode of life ; also 
that, even as regards the so-called healthy color of skin, considerable 

1 See under E. "^ See under Icterus. 



GENERAL EXAMINATION. 35 

individual variations exist. But, after all, the hue of the skin stands in 
intimate relation to a large number of diseases of the internal organs. 

It is considered most suitable to judge from the color of the counte- 
nance, the portion of the skin most generally reddened ; and, since on 
every hand we have opportunity for practice, it is well to sharpen the 
eye for critically examining this part of the body. But the color of the 
countenance can sometimes deceive us,^ and it is therefore advisable 
always to examine the mucous membrane of the lips, mouth, and 
throat,''^ and, besides, to observe the color of the skin of a part of the 
body usually covered by the clothing. 

We recognize the following abnormal colorations of the skin : 

1. The pale skin. 

2. The abnormally red skin. 

3. The blue-red cyanotic skin. 

4. The yellow skin of icterus. 

5. The bronze skin. 

6. The gray skin produced by nitrate of silver. 

I. The Pale Skin. — This can to a certain extent be physiological, 
especially in persons who spend little time in the open air. In these 
cases a glance at the mucous membrane gives further information. 
But one can be deceived regarding such persons, who, having exposed 
the face (also arms and hands) frequently to radiant heat or to cold 
and heat in rapid succession, often have a local redness of face. This 
redness of face may arise from other causes.^ 

Only experience can enable one to distinguish between physiologi- 
cal paleness and that produced by disease. The recognition of the 
latter is frequently aided in that it is associated with a grayish, yellow- 
ish, or, in a word, with a sickly, color. The color of the skin is pro- 
duced by the fulness of its capillary vessels. The abnormal paleness 
may be dependent upon disturbance of the circulation, and in conse- 
quence of diminished force of the heart or active narrowing of the 
peripheral arteries, or by a lessening of the quantity of the blood-con- 
stituents, chiefly of the hemoglobin. 

The redness of the skin depends upon the degree to which its capil- 
laries are filled with blood. There is abnormal paleness if either too 
little blood or too light blood is circulating in the capillaries of the 
skin. The causes of the morbid paleness are, therefore, on the one 
hand, disturbances of circulation — /. c. decrease of motor power of the 
heart as well as arterial spasm, or, on the other hand, deficiency of 
hemoglobin. It is an important diagnostic point to decide in all cases 
of paleness, first of all, to which of these two principal groups the pale- 
ness belongs. The surest diagnostic means, however, and the one 
which should always be applied if there is the least doubt, is the 
examination of the blood.* 

We distinguish {a) Temporaiy paleness, w\i\z\\ is partly physiological 
and partly pathological. It occurs with strong emotion, especially fright ; 

1 Vide especially under Red Skin. 

^ It is wrong in making a diagnosis of anemia to include the observation of the con- 
junctival mucous membrane. It is not decisive, since many persons in whom the teguments 
are elsewhere pale, at times easily have the conjunctiva injected. 

^ See under Red Skin. ^ See under Examination of the Blood. 



36 MEDICAL DIAGNOSIS. 

in syncope or fainting ; in the chill of fever, which ordinarily accompanies 
a rapid, considerable elevation of temperature ; in spasm of the capillary 
vessels ; in vascular spasm which occurs spasmodically, particularly in 
the extremities. This spasm is observed either as a simple vaso-motor 
neurosis or in connection with certain phenomena in the heart.^ (p) 
Paleness lasting a longer or sJwrter time. This comes on sometimes 
quite rapidly, at least in the course of a few moments, during profuse 
hemorrhage and in sudden collapse — that is to say, in sudden failure 
of the heart as it occurs in acute, and sometimes chronic, diseases, and 
in acute poisoning. The sudden paleness in consequence of the loss 
of blood or collapse is accompanied by acceleration and attenuation 
of the pulse, great weakness, and sometimes with disturbance of con- 
sciousness. 

External hemorrhages make themselves evident. But cases of 
severe internal hemorrhage, especially of the stomach or bowels, of 
ruptured aneurysm, hemorrhage from internal wounds of any kind, are 
declared only by this sudden paleness, sometimes even before the 
patients themselves, if quiet in bed, complain of weakness. 

In a case of endocarditis which I saw the patient became pale, as 
one does from an internal hemorrhage, with increased frequency of 
pulse and stupor, within less than ten minutes. At the autopsy there 
was found a recent total rupture of an aortic valve. 

This paleness, spoken of under {p) above, can develop more slowly 
within a few hours or days by considerable repeated hemorrhages. 
In such a case the examination of the blood always shows it to be 
watery, deficient in hemoglobin, and often also in red corpuscles, 
because after losses of blood the watery constituent is always restored 
first. [This condition is called hydremia^ It develops as a symptom 
of weakening of the heart's activity in all acute and chronic diseases of 
the heart and pericardium ; also in diseases of parts adjacent to the 
heart, as pleurisy and abdominal affections, with much pressure upon 
the diaphragm in case they interfere with the action of the heart; 
finally, in many acute diseases, especially in diphtheria, in heart-failure 
from diseases affecting the muscular structure of the heart, and very 
often and very quickly in acute catarrh of the stomach (acute dyspep- 
sia). Here hydremia is connected with imperfect fulness of the blood- 
vessels. 

Finally, paleness of the skin comes on in certain conditions gener- 
ally unnoticeable, insidious, and is a chronic condition ; in the so-called 
special diseases of the blood and of the blood-making organs — indeed, 
most unfortunately, from a diminution of the hemoglobin, hence in 
chlorosis, also in pernicious anemia, leukemia, pseudo-leukemia. In 
this list also probably belongs malarial cachexia. Paleness is a 
symptom of all slowly-developing secondary anemias {cachexia) as 
they occur in a large number of diseases, such as all chronic febrile 
diseases, especially tuberculosis; in suppurations without fever; in 
continuing slight hemorrhages, as in many tumors and in ankylosto- 
miasis [Egyptian chlorosis] ; in all chronic diseases of the digestive 
tract ; in most diseases of the female generative organs ; in the dif- 
ferent forms of chronic nephritis, especially the large white kidney ; in 

^ Compare section on Circulatory Apparatus. 



GENERAL EXAMINATION. . 37 

chronic poisoning, especially by mercury or lead ; sometimes, also, in 
constitutional syphilis ; in malignant growths, especially in cancer 
proper; and in chronic diseases of the heart, but especially in fatty 
heart and mitral and aortic stenosis. 

In the first two of these three groups the coloring faculty — i. e. the 
faculty of the blood to redden the skin — is always more or less dimin- 
ished; but also the defective power of the heart may contribute to 
paleness. In the third group, that of heart-diseases, however, the 
principal causes are defects of the circulation. 

Often there exists not only paleness of the skin, but its color has a 
still further characteristic appearance. In severe anemias we have a 
peculiar waxy appearance, which not rarely has a yellow tone. A 
striking, light white skin often exists with the so-called large white 
kidney (chronic parenchymatous nephritis), also in a certain proportion 
of the cases of lead-poisoning (which latter is often of a grayish white), 
of leukemia, and of tuberculosis. In chlorosis the skin has a greenish 
hue ; in diseases of the heart-muscle and in mitral insufficiency the 
skin is generally a smutty yellow, while in the cachexia of cancer it is 
often gray-yellow. 

Often a large development of adipose tissue strikingly contrasts 
with a pathological paleness, and this is especially to be seen in dis- 
eases of the blood, particularly in chlorosis and pernicious anemia and 
also in heart-diseases. In both cases, however, one must be careful 
not to be deceived by the presence of edema.' 

3. Abnormal Redness of the Skin. — This expression compre- 
hends a superfluity of normal blood, because up to the present time 
we do know of such a condition — i. e. a genuine plethora. 

General abnormal redness of the skin is always a sign of a general 
hyperemia of the cutaneous capillaries, and it occurs in high fevers, 
especially in continuous fevers. It also is present during the perspira- 
tion following a warm bath. Finally, in poisoning with atropin, even in 
very mild cases, it is developed like the redness of scarlet fever. (The 
scarlet-fever redness, being connected with a disease of the skin, does 
not belong here.) 

Local redness, depending upon a dilatation of the capillaries, exists 
very frequently in the face, and indeed is physiological in those who 
labor in the sun. It comes and goes quickly, as in blushing {rubor 
pudicitice), in nervously excitable persons in consequence of very 
slight psychical impressions, also not infrequently as a result of 
physical exertion. Moreover, we see redness of the face in fever; 
finally, one-sided redness of face in the " paralytic " form of hemi- 
crania. 

Tuberculosis is characterized by a very marked variation in the ful- 
ness of the capillaries of the face : if the patients are entirely at rest 
and without fever, they are generally pale, but under excitement or 
exertion, after eating, and, lastly, during fever, they exhibit a very 
striking, generally bright, redness of the cheeks and often a sharply- 
defined spot (hectic redness). 

In the slight forms of anemia, especially if associated with ner- 
vous irritability of heart, likewise with local vaso-motor disturb- 

^ Compare p. 47. 



'38 MEDICAL DIAGNOSIS. 

ances, there is sometimes intense redness of the face which may con- 
ceal the anemia from the physician. 

For distinction of circumscribed hyperemia from Hemorrhage in 
the Skin, see under the latter. 

3. The Blue-red Skin, Cyanosis. — This is most plain on the 
parts that normally are bright red, hence more than elsewhere on the 
mucous membranes, on the lips, cheeks, etc. ; also on the knees, the 
phalanges of the fingers, and under the finger-nails. A moderate 
degree of cyanosis, therefore, would only be discovered at these parts. 
A marked degree, on the other hand, exhibits a blue color spread over 
the whole body, while those parts, especially the mucous membrane, 
become black-blue. 

The cyanosis of the new-born, with heart-failure, is so striking to 
the experienced observer that it is regarded by him as pathognomonic. 
This symptom occurs, according to the gravity of the organic changes, 
either persistently or only after exertion. The popular name for it is 
" blue disease." One only sees anything Hke it in the death-agony 
and, exceptionally, in severe spasms with marked interference with 
breathing. The combination of cyanosis with great paleness is desig- 
nated as " livid skin." 

Cyanosis arises from the blue-red color of the capillaries, and this, 
as is well known, is caused by an accumulation of carbonic acid and 
deficiency of oxygen — that is to say, by the venous or hypervenous 
character of the capillary contents. 

Carbonic acid in the blood (serum and red corpuscles) arises from 
— I. Interference with the exchange of gases in the lungs ; 2. From 
the slowing of the capillary circulation and the consequently dimin- 
ished gas-exchange in the tissues — that is to say, the diminished giving 
up of CO2 by the tissues to the blood. 

Cyanosis arises, therefore — i. In disturbed respiration and circula- 
tion through the lungs ; 2. In disturbance of the " greater circulation," 
which may be general or circumscribed according as the stoppage may 
be general or local. The two causes may be combined. 

Here belong to 1 — 

(a) All conditions which cause a jtarrowing of the larger air-passages 
or of a large number of small bronchi : inflammation of the neighbor- 
hood of the pharynx or entrance to the larynx ; retropharyngeal 
abscess, angina Ludovici ; very exceptionally a diphtheria of the throat. 
(In all of these cases the interference with respiration is either direct or 
dependent on edema of the glottis.) Here belong also those rare, 
sudden obstructions of the pharynx by foreign bodies, as a piece of 
meat and the hke. The following are enumerated : spasm of the 
glottis, paralysis of the dilator of the glottis (crico-arytenoideus post.), 
all acute and chronic inflammations of the larynx, but especially croup ; 
tumors of the larynx ; cicatricial narrowing of the larynx ; foreign 
bodies in the larynx (something swallowed or vomited) and wounds of 
this organ ; also foreign bodies, croup, and scars in the trachea or one 
or both primary bronchi ; compression of these from without by en- 
larged glands ; aneurysm of the aorta ; mediastinal tumors, etc. ; severe 
diffuse bronchitis, especially the acute croupous form ; bronchial 
asthma. 



GENERAL EXAMINATION. 39 

{B) All diseases of the lungs and diseases of the chest-cavity and its 
neigJiborhood which hindei'- the expansion of the lungs or wJwlly com- 
press them: emphysema of the lungs; all forms of consolidation; 
pleuritic and great pericardial exudation ; pneumothorax ; tumors in the 
chest-cavity; abdominal diseases with marked upward pressure of the 
diaphragm. 

In these conditions there exists also a disturbance of the pulmonary 
circulation, apart from the immediate interference with respiration. In 
emphysema a great many capillary blood-vessels are obliterated, which 
is also the case in tuberculosis and chronic pneumonia. Severe exuda- 
tive pleurisy and pneumothorax, on the other hand, produce oblitera- 
tion of capillaries by compression. The afflux of blood to the respir- 
atory surface of the lungs is in such cases consequently always dimin- 
ished, and this is an additional cause of dyspnea. 

(c) Paralysis of the respiratory muscles : bulbar paralysis; peripheral 
neuritis ; paralysis of diaphragm from peritonitis ; spasm of the mus- 
cles of respiration ; epilepsy, tetanus, but, on the other hand, very rarely 
hystero-epilepsy ; special muscular diseases; myopathic forms of pro- 
gressive muscular atrophy, trichinosis, myositis ossificans. 

Disturbances of the circulation through the lungs occur in a num- 
ber of the diseases which interfere with respiration. In emphysema a 
large number of capillary channels are closed, also in tuberculosis and 
other chronic lung affections ; a large pleural exudation not only com- 
presses the lungs, but also the capillaries. This acts in the same way 
as a hindrance to respiration. 

(d) Diseases of the heart which residt in obstruction of the pidmonary 
circidation. In several of these conditions, especially inflammatory dis- 
eases of the pleura, of the peritoneum, in trichinosis of the diaphragm, 
the insufficient breathing, as well as the cyanosis, will be increased by 
the pain caused by the act of breathing. This circumstance is of great 
practical utility, because a part of the dyspnea, as well as of the cyano- 
sis, can be removed by alleviating the pain which is the result of the 
act of respiration. 

In persons very much wasted, especially from tuberculosis, cyanosis 
may be absent even in spite of the loss of a large part of the breathing- 
surface of the lungs, since the remaining normal portion suffices for 
supplying the required quantity of oxygen to the diminished quantity 
of blood. 

Under heading 2 : 

Slowing of the blood-curre7it in the capillaries of the greater circida- 
tion is dependent upon stopping of the venous outlet. This can be 
general, and caused by all the conditions of the first category, general 
cyanosis, or it can be occasioned by a venous stopping of an extremity 
or of the head, and so produce a local cyanosis. 

General venous stasis occurs in diminished motive power of the 
right ventricle (valvular deficiency, congenital stenosis of the pulmo- 
nary artery, diseases of the heart-muscle, large pericardial exudation 
with hindering of the heart's action, considerable emphysema of the 
lungs with excessive damming of the smaller circulation), and in the 
rare case of compression of a large venous trunk just before it enters 
the right auricle (tumors of the mediastinum). 



40 * MEDICAL DIAGNOSIS. 

Local vcnojis stasis is caused by closure or marked narrowing of a 
more or less large venous trunk. This closure may be produced by 
compression or by thrombosis of the vein (compression of the cava or 
the extremity of a venous trunk by tumors) ; by compression of the cava 
inferior in connection with the common iliac artery by very large 
effusion in the peritoneum or by tumors ; by atrophic thrombosis of a 
vein of the extremity, especially the femoral. Not infrequently the 
collateral veins of the skin take up the conveyance of the blood of the 
venous stasis ; they then become enlarged and sometimes tortuous.^ 

For the cyanosis produced by certain poisons, see Examination of 
the Blood. 

4. The Yellow Skin, Icterus, Jaundice. — The jaundiced state 
of the skin exists in well-marked cases, with sHght differences, almost 
equally over the whole surface of the body. It is found especially in 
the conjunctiva, and in slight cases exclusively there and in the other 
mucous membranes, if the observer will render the spot anemic by 
pressure (best done by means of a microscopic slide pressed upon the 
everted lip or upon the tongue). According to the intensity of the 
jaundice, the tissues are but slightly tinged with yellow or citron color 
or yellow-green. Only in very severe cases (melas-icterus) does the 
skin become green or brownish-yellow. 

Jaundice cannot be detected by the ordinary means of illumination, 
since the yellow artificial hght does not enable one to distinguish be- 
tween white and yellow. In slight cases it will first be detected in the 
conjunctiva. But this must not be confounded with the yellow fat that 
sometimes exists there, especially in elderly people. In persons with 
yellow or brown skin the jaundice is revealed by an examination of the 
mucous membrane. 

The yellow color of the skin after taking picric acid or santonin has 
no relation to jaundice. We distinguish this condition from jaundice 
by analysis of the urine {q. v) and by determining the etiology of the 
former. 

The icterus of the surface of the body which can be clinically 
demonstrated is the partial evidence of the distribution of the yellow 
coloring matter through the whole organism with the exception of a 
few tissues. It is caused almost without exception by the presence of 
biliary pigment in the blood. Biliary pigment, however, seems to be 
formed exclusively in the liver. At least we know, according to the 
researches of Naunyn and Minkowski, that this is the case in geese 
and ducks, and there is no reason to suppose that it is different in man. 
The icterus caused by biliary pigment points, therefore, always to 
abnormal processes in the liver, and these processes are of such a kind 
that they culminate in a transference of biliary constituents into the 
blood. 

We may say that the cases in which we observe icterus, with very 
few exceptions to which we will revert later, are divided into two large 
groups : either we have to do with purely mechanical, so-called icterus 
of stagnation (hepatogenous icterus) or with the hemogenous, better 
hemo-hepatogenous, icterus. 

I. The so-called hepatogcnotts icterus, icterus of stagnation, is the 

^ Vide Examination of the Veins. 



GENERAL EXAMINATION. 4 1 

result of an interference with the flow of bile from the liver by an 
obstruction in the large or in many small biliary ducts, or at the place 
of entrance of the ductus choledochus into the intestines. This pro- 
duces stagnation of the bile in the liver and the transference of it into 
the blood. The causes of this most frequent form of icterus are — 
(gastro-) duodenal catarrh, with catarrhal swelling of the mucosa and 
accumulation of mucus in the ductus choledochus ; tumors which 
press upon the duodenal orifice of the ductus choledochus, and espe- 
cially cancer of the head of the pancreas ; ascarides or round-worms 
{q. V.) which enter the ductus choledochus ; and also gall-stones which 
lodge there. 

There may be compression of the hepatic duct or of the large gall- 
duct at the entrance of the liver by tumors (carcinoma, echinococcus) 
or by scars or by closure of the same by gall-stones. Closure of 
many small bile-ducts may be caused by so-called intrahepatic gall- 
stones ; possibly also compression of these by marked damming in the 
branches of the veins of the liver from general venous stasis ; finally, 
catarrh of the smallest bile-ducts may possibly cause bile-stasis and 
jaundice, as in phosphorus-poisoning. 

One consequence of the presence of biliary constituents in the blood 
is that they make their appearance in the urine. Therefore, the urine 
in icterus caused by stagnation, with the exception of very light cases, 
always contains demonstrable qualities of biliary pigment, and some- 
times also of bile acids. 

In case the flow of bile is much hindered or is wholly stopped, then, 
partly from the want of bile and partly from the fatty contents, the 
stools become light, perhaps entirely white or gray-white.^ 

In some cases of severe jaundice there may be still other appear- 
ances — itching, various skin affections, minute cutaneous hemorrhages, 
slowing of pulse, or simple nervous manifestations. In very severe, 
long-standing jaundice there may be marked heart-disturbances, 
hemorrhagic diathesis may develop, or, finally, there may arise severe 
nervous manifestations (cholemia, cholemic manifestations). 

2. Hemo-hepatogenous Icterus. — It has been long known that icterus 
occurs in certain cases of poisoning and in certain infectious diseases. 
These conditions have the common feature that they are accompanied 
by a marked alteration of the blood, which is chiefly characterized by 
a dissolution of the red corpuscles and by hemoglobinemia. Formerly 
it was supposed to be most probable that in such cases hemoglobin- 
hematoidin, which is identical with bilirubin, was formed in the blood 
from hemoglobin, and that, consequently, there was produced a 
genuine blood-icterus. We have, however, mentioned above that in 
certain animals, and probably also in man, the liver alone is to be 
regarded as the place of formation of bilirubin. It has farther been 
demonstrated by Afanassiew and Stadelmann that in cases of dissolu- 
tion of the blood by poisons a great amount of bile is secreted which 
is very rich in biliary pigment and is very thick. As a consequence, 
the biliary ducts are insufficient to carry off this bile, and thus there is 
a secondary stagnation of bile in the liver. It is therefore to be sup- 

^ The particulars of this condition of the stools and of the urine in jaundice are explained 
in the chapters devoted to these subjects. 



42 MEDICAL DIAGNOSIS. 

posed that in primary alterations of the blood icterus is produced by- 
stagnation of bile in the liver. 

The form of icterus which is dependent on a dissolution of the blood 
is seen in certain poisons : by chloroform, ether, chloral, chlorate of 
potash, solution of arsenic, toluylendiamin ; in certain infectious dis- 
eases, etc., pyemia, yellow fever, sometimes in pneumonia. Here, how- 
ever, it is necessary to add that probably compHcating disease of the 
liver may have some share. 

In primary icterus of stagnation we expect to find biliary pigment 
in the urine, and this is usually the case, but not always. Here is a 
weak point in the doctrine of hemo-hepatogenous icterus. However, 
we must not overlook the fact that in this form of icterus the feces are 
not discolored, because there is a deficiency of bile in the intestines. 

We will not omit to emphasize the fact that icterus does not always 
follow dissolution of the red corpuscles, with formation of hemo- 
globinemia. Slight hemoglobinemia — for instance, in slight cases of 
poisoning, in moderate burns — produces neither icterus nor alterations 
in the urine ; and even more severe cases of hemoglobinemia may 
cause hemoglobinuria without icterus. On the contrary, only in the 
most severe cases of hemoglobinemia is there such a degree of poly- 
cholia or inspissation of bile as to cause icterus. 

Icterus Neonatorum. — We understand by this a very benign variety 
of jaundice which appears in a considerable number of new-born babies 
during the first days of life. The explanation of this disease, however, 
is doubtful. Purely mechanical conditions (the sudden decrease of 
pressure in the vena porta — Frerichs), as well as processes in the blood 
(Hofmeier), and other things, have been indicated as causes of the con- 
dition ; but none of these explanations has been fortified by exact 
proofs. 

There are still other cases of icterus which cannot be included in 
the two great categories mentioned above. First of all are cases in 
which no biliary coloring matter can be found in the urine. In most 
of these cases the color of the skin is not definitely icteric, but only 
slightly yellowish, often dirty yellowish, much resembling the skin 
sometimes seen in chronic diseases of the liver, especially in alcoholic 
cirrhosis and in persons suffering from heart-disease, but also in acute 
infectious diseases. In the last-named diseases particularly there occurs 
severe icterus without icteric urine ; for instance, in pyemia. From this 
it may be supposed that jaundice may originate from something else 
than bilirubin in the tissues. 

Urobilin-icterus. — In a minority of the cases just mentioned there is 
found in the urine, instead of bilirubin, great quantities of a substance 
related to it, hydrobilirubin or urobilin, which substance is formed from 
bilirubin by reduction with sodium amalgam, but also under the in- 
fluence of the bacteria of decomposition ; and this substance is also 
found in the urine during resorption of extravasated blood.^ It has 
been believed that in the cases of icterus mentioned above, where no 
biliary pigment, but urobilin, appeared in the urine, the urobilin was 
the cause of the icterus (urobilin-icterus — Gerhardt and v. Jaksch). But 
F. Miiller has lately adduced important reasons against the existence 

1 See chapter on Urine. 



GENERAL EXAMINATION. 43 

of an icterus caused by urobilin, which reasons we cannot here dis- 
cuss.^ 

D. Gerhardt^ in a series of cases of different kinds of icterus, some 
of them of the sHghtest degree, always found bilirubin in the blood- 
serum and in the tissue-lymph. From this we are to infer that, con- 
trary to what has been said above, icterus would always be caused by 
biliary pigment. Whether this view will be confirmed is still doubtful. 

It is uncertain where urobilin is formed. Tissier recently asserted 
that it is principally formed in the liver. Healthy liver-cells produce 
bihrubin out of hemoglobin ; diseased liver-cells or those damaged in 
any manner, however, produce urobilin or certain substances inter- 
mediate between these two. Severe urobilinuria only makes its appear- 
ance in cases of chronic disease of the liver if there exists an increased 
dissolution of red corpuscles. On the other hand, F, Miiller thinks 
that urobilin is formed in the intestines. He says it is formed by the 
bacteria of putrefactioh by reduction from bilirubin. He did not find 
it in the feces and the urine when no bile entered the intestines, and 
likewise as long as there was no putrefaction in the intestines, as in the 
new-born. But it is not feasible to discuss this interesting question 
more in detail here. 

5. The Bronze Skin. — Unlike cyanosis and jaundice, this is a 
condition pertaining only to the skin and mucous membrane. We 
speak of the chief symptom instead of the true anatomical seat of the 
disease — viz. the suprarenal capsule, the so-called Addison's disease. 
It is regarded as a disease of the suprarenal capsule, more frequently 
tubercular. Connected with it is a degeneration of the ganglia and of 
the ramifications of the sympathetic nervous system. [The association 
of this peculiar brown discoloration of the skin is not constant in Ad- 
dison's disease. It is not so constant in cancerous, but is more 
common with cheesy, degeneration. The latter condition may be 
present without bronzing of the skin. On the other hand, the skin 
maybe bronzed, just as "in Addison's disease, without the existence 
of cheesy degeneration or any other change in the suprarenal capsules. 
These facts have induced many observers to attribute the cutaneous 
discoloration rather to changes in the neighboring sympathetic nerves 
— the solar plexus and the semilunar ganglia."] 

The bronze skin is characterized by a brown, gray to black dis- 
coloration, especially of the face and hands. There is also the common 
normal pigmentation of the skin in spots. The discoloration may 
gradually extend over the whole surface of the body, only the nails 
and cornea remaining clear. 

It is very important to notice that the same discoloration appears 
upon the mucous membrane of the mouth, and more rarely upon the 
lips, as very sharply circumscribed, frequently quite small, brown 
specks. 

The discoloration is caused by deposit of pigment in the rete Mal- 
pighii. Of course pressure with the finger does not at all diminish it. 

Arsenical Melanosis. — When arsenic has been administered for a 
long time, sometimes even though the doses be small, there is pro- 
duced a discoloration of the skin, and likewise of the mucous mem- 

^ See chapter on Urine. '^ Diss., Berlin, 1889. 



44 MEDICAL DIAGNOSIS. 

brane of the mouth, which in every particular resembles Addison's 
bronze skin This condition is called arsenical melanosis. After the 
arsenic has been discontinued the discoloration only imperfectly disap- 
pears or it may persist. 

6. The Gray Skin of Silver Deposit. — After long-continued 
administration of nitrate of silver there may be deposits, in certain 
organs, of very fine black particles (metallic silver or silver albumi- 
nate ?), as in the kidneys, intestine, and also in the skin, and especially 
in the corium, the tunica propria of the sweat-glands. 

The skin of such persons, especially of the face and hands, is gray 
or blackish. The color is not changed by pressure. In severe cases 
we also observe corresponding gray specks in the mucous membrane 
of the mouth. 

In a strict sense this is not a diseased condition : the function of the 
organs which are impregnated with silver do not seem to be in the least 
disturbed, and these people are perfectly well. 

D. Other Pathological Appearances of the Skin of General 
Diagnostic Value. 

I. Acute Bxanthematous Diseases. — In some acute infectious 
diseases a characteristic eruption of the skin has so marked an appear- 
ance that these diseases are designated as '' acute exanthemata." They 
are — scarlet fever, measles, German measles, small-pox, and varicella. 
Here we may pass over the cutaneous diseases which belong here, 
since they are closely connected with the complete description as these 
diseases are taught at the bedside. 

On the other hand, there are certain other acute exanthematous 
diseases, less striking, but at the same time of great diagnostic im- 
portance. We may here briefly mention — 

{a) Roseola. — This presents a small, round, rose-red, slightly ele- 
vated spot. It is generally scattered, is found most frequently upon 
the abdomen and lower part of the back, more rarely upon the breast 
and extremities in typhoid fever. It appears about the beginning, and 
generally fades at the end, of the second week. Now and then sec- 
ondary roseolar spots appear later, which are connected with exacerba- 
tions of the disease (involving new portions of the intestine ?). 

Secondly, it appears in the form of somewhat larger spots and in 
the great majority of cases of typhus fever. But, except in light cases, 
it is in this disease petechial — i. e. the location of small hemorrhages, 
which are slowly absorbed. In the beginning of the disease it is often 
not easy to distinguish this roseola from the eruption of measles. 

Further, roseolar spots exist in some cases of acute miliary tuber- 
culosis, and finally in animal poisoning. 

Finally, it is necessary to refer in this place to roseola syphilitica 
and to an eruption which appears in the form of small, flat (not raised) 
spots — erythema exiidativinn midtiforine. 

(b) Herpes Facialis. — This consists of a group of small vesicles 
upon a slightly red base. The vesicles contain at first clear water, then 
are cloudy, then yellow from pus contained in them. They may be 
confluent. After a few days they dry up and scale. Most frequently 



GENERAL EXAMINATION. 45 

this exanthem is found in the neighborhood of the mouth — herpes 
labialis ; or of the nose — herpes nasalis ; it may also appear upon the 
cheeks or the ear. 

It makes its appearance at the beginning of some acute diseases, 
and seems to be especially peculiar to very rapidly rising fever. Above 
all, it accompanies croupous pneumonia, then epidemic cerebro-spinal 
meningitis, in which disease it is often quite extensive, finally, sometimes 
in angina {angina herpetica), and a light febrile disease named, in con- 
sequence, febris herpetica. 

An herpetic eruption also sometimes accompanies the development 
of interniitteitt fever and the cJiill of pyemia. 

(c) Miliaria, Sudamina. — These are small, remarkably clear vesi- 
cles, which reflect the light strongly. Generally they occur in large 
numbers, especially upon the abdomen. They appear. if a patient, after 
long-continued anhidrosis, begins to sweat profusely, especially in acute, 
but also sometimes in chronic, diseases. They contain perspiration, and 
hence the drop which appears after they have been punctured reddens 
blue litmus-paper. 

Still other exanthemata of diagnostic importance could be mentioned 
here, as the rare scarlet redness in the beginning of typhoid fever, the 
different eruptions of sepsis, pyemia, and other diseases. 

2,, Exanthemata from Poisons and the Use of Medicines. 
— These are of varied character, since they sometimes resemble those 
of acute diseases — viz. scarlet fever, measles, etc. They may, therefore, 
easily cause an error in diagnosis. The medicines or poisons which 
most frequently produce exanthems are — quinin, antipyrin, salicylic 
acid, opium, morphin, atropin, strychnin, balsams, particularly balsam of 
copaiba, iodin, bromin (and substances applied locally, vesicants, as 
mustard). The particulars regarding them belong to works on dis- 
eases of the skin, and also to pharmacology and toxicology. 

3. Hemorrhages in the Skin. — They arise, it appears, chiefly 
by diapedesis, and seldom only by rupture of blood-vessels {rhexis), 
and take place by preference, but not exclusively, in dependent parts, 
especially the lower extremities. They may be of any size — from 
the smallest perceivable point to the size of the palm of the hand or 
even larger. The small, punctiform hemorrhages, ecchymoses or 
petechiae, are most apt to appear at the hair-follicles. When the 
hemorrhages are fresh the color is like venous blood. During ab- 
sorption they are brown-red, later becoming bright brown. 

A hemorrhage is distinguished from a circumscribed inflammatory 
redness of skin in that it does not disappear npon pj'essure. (The small 
ecchymoses in the hair-follicles, mentioned above, are easily confounded 
with the latter, especially in cyanosis ; further, petechiae in parts pre- 
viously inflamed, as in measles, are easily overlooked.) 

Simplest test : Press a piece of glass, a microscope slide, upon the 
suspected spot. A hemorrhage is rendered more distinct, while the 
surrounding part becomes anemic ; an inflammatory hyperemia, on the 
other hand, disappears. 

Hemorrhages take place— 

I . As evidences of a marked hemorrhagic diathesis. They are then 
generally extensive in the skin, and, moreover, occur in connection 



46 MEDICAL DIAGNOSIS. 

with hemorrhages from internal organs. They occur in scorbutus, 
purpura haemorrhagica ; in severe acute infectious diseases, especially 
pyemia, small-pox, and scarlet fever ; in acute phosphorus-poisoning 
and acute yellow atrophy of the liver ; and in all severe cachexiae. 

2. Without inter 7ial JicniorrJiagcs, as a condition limited to the skin : 
in peliosis rheumatica \i. e. purpura occurring with severe pain in the 
extremities] ; also as small petechiae ; almost constantly in typhus 
fever,^ often in measles and scarlet fever ; moreover, on the legs when 
the convalescent patient first stands up, especially after typhoid fever ; 
and in badly nourished persons where they have been bitten by 
pediculi. 

3. I?i marked venous stasis, local as well as general.^ Here belong 
those punctiform extravasations of blood which are occasionally seen 
on the face, particularly on the temples, after severe epileptic and 
eclamptic convulsions and after severe attacks of whooping-cough. 
More frequently occur here extravasations of blood in the conjunctiva. 

4. As traumatic hemorrhages in and ufider the skin. They are 
sometimes of importance for determining the occurrence of an injury, 
especially upon the skull. 

4. Scars. — These are often important marks for limiting or ex- 
plaining the clinical history, which, by reason of the scars, can be 
confined to past local or general diseases or to injuries received. 

Thus come under consideration " pock " (small-pox) marks and the 
scars which may remain after the different scrofulous and syphilitic dis- 
eases of the skin and deeper organs, especially the bones and glands. 
In internal medicine scars from injuries have importance in many 
nervous diseases (injuries upon the head, the spine, in the course of 
peripheral nerves). 

Here also belong the scars of pregnancy — strice upon the lower 
part of the abdomen and the upper part of the thigh. Exactly the 
same scars occur in marked edema,^ and also sometimes in very fat 
persons. 

5. i^ctasia Venarum. — Varices. — Visible nets of veins properly 
belong here, but they will be described in the section on " The Cir- 
culatory Apparatus." 

E. Edema of the Skin and Subcutaneous Cellular Tissue (Edema, 

Anasarca). 

By these terms we designate an abnormal, marked saturation of the 
tissues with fluid, which fluid remains wholly or in part distributed in 
the cellular meshes and lymph-spaces of the tissues, instead of a cor- 
responding quantity of fluid existing in bulk, as its transudation takes 
place from the blood-vessels to be removed by the lymph-current. 

Edema is recognized by puffiness of the skin causing increase of 
volume of the affected part, and hence, also, the normal outline on the 
limbs and the trunk are obliterated in consequence of the filling up of 
the depressions and cavities, and, moreover, there is a tendency to an 
equal roundness. The skin is smooth, generally slightly shining, and 
hence, when the edema is marked, very pale in consequence of the 

^ See Roseola. * See Cyanosis. ^ See the following section. 



GENERAL EXAMINATION. 47 

diminished circulation. It is very noticeable that the edematous tissue 
loses its elasticity, so that a depression made by the point of the finger 
remains for a certain time, sometimes for hours. 

Where there is dropsy or a dropsical disposition of the whole body, 
as in heart and kidney diseases and severe anemias, we generally 
observe the anasarca first in the most dependent parts of the body, and 
later these are most affected. It also is most marked where the skin is 
most loosely attached, having loose connective tissues beneath it. 

Hence, in those persons who walk and stand it appears first at the 
ankles or on the dorsum of the feet (not on the soles and toes, since 
here the skin is too thick or closely attached) ; in bed-ridden patients 
on the inner side of the thigh or in the scrotum and penis, where it is 
often enormous ; on the lower part of the back ; sometimes, first of 
all, in the loose cellular tissue beneath the lower eyelid. One must 
examine all of these points if he would detect the first evidences of 
edema. 

In very marked cases the deeper parts, especially the muscles, 
become edematous ; the legs may then attain enormous proportions. 
Moreover, in marked general dropsy there are fluid accumulations in 
the cavities of the body, giving rise to hydroperitoneum or hydrops 
ascites, hydrothorax, hydropericardium. 

In long-continued edema the skin of the legs and, exceptionally, the 
lower part of the abdomen may become thickened, as in elephantiasis. 

We generally recognize three causes for dropsy of the skin : 

1. Venous stasis (hydrops mechanicus). 

2. Altered condition of the blood, particularly its becoming 

watery. 

3. Inflammations. 

Hence, these following corresponding diseases cause edema : 

1. All diseases, local or general, which hinder the return of venous 
blood to the right side of the heart, as those that have been already 
mentioned under " Cyanosis." ^ 

In local stasis the edema is naturally confined to the roots of the 
corresponding veins ; for example, thrombosis of the right crural 
vein causes dropsy of the right leg, or compression of the vena cava 
inferior by an abdominal tumor causes dropsy of both lower ex- 
tremities. 

2. All forms of hydremia (anemia), acute and chronic nephritis, in 
which the diminished excretion of water, on the one side, and on the 
other the loss of albumin from the blood, consequent upon the albu- 
minuria^ occasions the hydremia which is the chief factor in the 
condition which permits frequent and often marked edema. Yet the 
hydremia does not always explain the existence of the edema (Cohn- 
heim and Lichtheim).^ 

All other kinds of anemia, hydremia,'* come under this head when 
they appear as diseases of the blood or of the blood-making organs, 
and are secondary to the appearance of wasting diseases and severe 
acute diseases. Here we frequently see edema of the ankles in patients 
suffering from chlorosis or from cancer, also when the convalescent 
patient first stands up. 

1 See p. 38. 2 Which see. ^ See under Albuminuria. * See Blood. 



48 MEDICAL DIAGNOSIS. 

The anemia caused by long-continued slight hemorrhages (as those 
occurring in ankylostomo-anemia) may also lead to moderate edema, 
for here also we have hydremia, in that the loss of blood is replaced by 
water in the blood. 

3. Edema, sometimes of considerable extent, occurs in the ncigJi- 
borliood of inflaviviation ("inflammatory edema," "collateral edema"). 
This may be of great diagnostic importance, since it sometimes reveals 
a deep-seated inflammation. 

This is of more interest to the surgeon. To the physician it is 
important, for instance, in pleuritis with edema of the chest-wall. It 
shows, with tolerable certainty, that the pleuritis is purulent. Deep 
muscular abscesses in severe diseases, as in typhoid fever, may easily 
be overlooked, and may first be recognized by the appearance of 
edema in the neighborhood, as alonp; the femur, or the lumbar and 
gluteal regions. 

The edema in these different, but so heterogeneous, cases does not 
have a uniform character : that from stasis is sometimes soft, some- 
times very elastic, the latter especially (in marked stasis) exists in the 
extremities, when it is often difficult, and sometimes impossible, to 
leave the mark of the pressure with the finger; moreover, in cases of 
nephritis with a small quantity of urine and marked albuminuria it is 
sometimes very considerable, but now and then softer. In the different 
anemias the edema is mostly slight — a scarcely noticeable pufifiness. 
Slight edema disappears between morning and evening or evening and 
morning, according to the change of position of the body. 

Some differences as regards the localization of the edema can be 
recognized. In patients suffering from heart-disease, for instance, there 
is a decided tendency to have edema affect the most dependent parts, 
as the lower limbs, and also the parts of the body most distant from 
the heart, since the circulation suffers there sooner than elsewhere. 
Both of these conditions are fulfilled in the dependent feet and hands. 
But in nephritis the influence of gravity frequently cannot be well 
recognized : for instance, the edema appears only in the eyelids. 
Again, the sHghter edemas in acute nephritis and also in chronic inter- 
stitial nephritis (Bright's disease) are strikingly transient. It is also to 
be observed that in severe and long-continued acute nephritis, as well 
as in all forms of chronic nephritis, if the heart-power is weakened we 
have cardiac dropsy. 

The question, Why does edema result from venous stasis, hydremia, 
or inflammation ? has not in all respects been satisfactorily answered. 
Until recently it seemed to be proved that this is entirely to be ascribed 
in these three conditions to an injury of the endothelium of the vessels, 
and by this means occasioned increased transudation into the tissues 
(Cohnheim). Later, the view has been advanced, and it seems to me 
has become well established, that the loss of elasticity and the dimin- 
ished squeezing-out of lymph from the tissues by their being relaxed 
plays an important, perhaps a chief, part in causing edema (Landerer). 
This relaxation of the tissues might be caused by the stasis from the 
increased transudation, or by the hydremia from the deficient nourish- 
ment of the tissues by the morbidly thin blood, or, finally, it might be 
caused by inflammation excited in the neighborhood. 



GENERAL EXAMINATION. 49 

In conclusion, we must not omit to mention that, in rare cases, 
edemas occur which do not come under the above-mentioned heads — 
which, moreover, are not accompanied by any other morbid disturb- 
ances. Here belong the essential edema of children and the edema of 
the feet after forced marches. 



F. Emphysema of the Skin. 

By emphysema of the skin is understood the entrance of air into 
the cellular tissue. It may be limited to one region of the body, as 
the neck or the upper part of the chest or the upper part of the abdo- 
men ; but it may be spread over almost the whole of the body. It is, 
in general, a very rare condition. 

We recognize emphysema of the skin by the marked paleness over 
a region which is decidedly elevated above its surroundings. Indeed, 
on account of the loose fixation of the skin in certain parts, even de- 
pressions, as that over the clavicle, or the axillary space, or the inter- 
costal spaces, may be filled up, so that thus sometimes on a first glance 
at the part it seems like marked edema. Sometimes at such places 
there may even be an elevation of the skin Hke a pillow. Upon palpa- 
tion we find that the part is very yielding, like a soft pillow. Quite 
unlike edema, however, the depression made by pressure immediately 
disappears. Moreover, upon palpating the part we feel and hear an 
unusually fine crackling. 

The so-called aspiration^ emphysema of the skin does not here con- 
cern us. It arises from decomposition of a blood-extravasation or 
abscesses with formation of putrid gases. 

The so-called emphysema of skin from aspiration arises from the 
entrance of air or gas into the subcutaneous tissue, either from without 
through a wound of the skin or from within from an organ containing 
air or gas. 

(a) The entrance of air from without after a wound of the skin 
belongs to surger^^ This occurrence is especially observed in wounds 
of the neck (tracheotomy), of the breast, in the lower part of the face, 
and even in wounds of the mucous membrane of the mouth. The 
wounds in question are sometimes remarkably small. 

(U) Of much greater interest in itself, as well as from a diagnostic 
point of view, is emphysema from air or gas entering the cellular 
tissue from within. Under all circumstances it is occasioned by the 
rupture, either spontaneously or traumatically, of the wall of an organ 
containing air or gas. Hence emphysema of the skin may arise — 

I . From any portion of the respiratory tract, from the larynx down. 
Deep-seated ulceration of the larynx or trachea may invade the walls 
of these organs, and thus the air may escape and enter the subcu- 
taneous cellular tissue. 

Cavities of the lungs (after previous repeated adhesions between the 
pulmonary and parietal pleura) may ulcerate into the chest-wall, until, 
finally, communication with the cellular tissue is established. Then the 

^ The name "emphysema" is not quite accurate, since generally the air is driven in 
under pressure, as is shown by what follows. 

4 



50 MEDICAL DIAGNOSIS. 

pressure of a severe paroxysm of cough may cause the air in large 
quantity to spread out quickly under the skin. 

Single pulmonary alveoli may burst from any very high intra- 
thoracic pressure, as severe cough, especially in children with whooping- 
cough, bronchitis, or emphysema ; sharp crying ; severe exertion, as 
blowing on wind instruments, or women in childbirth ; and air may 
enter under the pleura or into the interalveolar tissue, reach the medi- 
astinum, pass along the mediastinal space into the subcutaneous tissue 
of the neck, and so spread onward. 

Wounds of the lungs (as fracture of the ribs without external 
wound) may either directly cause emphysema of skin, or, passing the 
mediastinum as above, take the same course. 

2. From the esopliagus, stomach, or intestines, and, indeed, from the 
esophagus again through the mediastinum : from the stomach or intes- 
tines by adhesions with the abdominal wall and invasion of the cellular 
tissue there; from traumatic rupture of the esophagus, more frequently 
from ulceration, especially in connection with carcinoma of the esopha- 
gus ; with any kind of deep seated ulcerations of the stomach and 
bowels. 

Sometimes there occurs extensive decomposition of the cellular 
tissue, especially if emphysema of the skin is produced by gases from 
the intestinal canal (mixed with intestinal contents). Very often, how- 
ever, the emphysema remains without such action. It may then spon- 
taneously disappear. But, at the same time, the emphysema is 
generally a final development, partly on account of the severity of the 
primary disease, and partly because it causes severe dyspnea, as, for 
instance, that in the mediastinum, and hence is a very serious con- 
dition. 

From a diagnostic point of view emphysema of the skin is of great 
importance, since it affords a conclusion regarding the diseases men- 
tioned. Under some circumstances it may afford the first and only 
symptom, as in the affections of the esophagus. 

V. THE TEMPERATURE OF THE BODY. FEVER. 

It is a well-known peculiarity of warm-blooded animals, if the or- 
ganization is otherwise sound, that with remarkable constancy they 
maintain a certain internal temperature which is subject to very slight 
variations. If that peculiarity is lost, if the temperature departs from 
the normal, then, almost without exception, a morbid disturbance is 
present. A knowledge of this fact, and especially of the elevation of 
the specific heat in disease, attracted the attention of physicians to the 
temperature of the body from the earliest time. Recently, however, 
the measurement of the temperature has become of the greatest diag- 
nostic aid, indispensable for every scientifically educated physician. 

I. The Terms Used and the Method of Taking the Tem- 
perature. — Judging of the temperature by laying on of the hands is 
under all circumstances deceptive. Great errors cannot be avoided even 
if covered parts of the body are selected, while uncovered parts cool so 
rapidly as to furnish no standard. 

We measure the temperature with the Centigrade or Celsius's ther- 



GENERAL EXAMINATION. 51 

mometer, with the scale divided into tenths, from about 30° to 45^. 
There is no need for a thermometer with indications below 30°.* 

In France the Reaumur scale is sometimes used ; in England and 
America the Fahrenheit is generally used. To convert from one 
standard to another the following formula is used : 

i°C = r R- = (fH-32)°F. 

It is further to be remarked that in Germany still, especially at the 
public baths, the baths are frequently measured and are prescribed 
according to the Reaumur standard. 

As regards the selection of the instrument, it is to be recommended 
to use only officially tested thermometers, which are provided with a 
number and a certificate as to their correctness. The price of them is 
a little higher than that of those which have not been tested. The 
guarantee for the correctness of the tested instruments extends, how- 
ever, only a certain time. As the glass changes a little in the course 
of time, it is necessary to have them again tested after a few years. 
Thermometers without a test certificate offer of course less guarantee 
for correctness. Always before using such a thermometer one should 
compare it with a so-called normal thermometer. But as normal ther- 
mometers are very expensive, officially tested ones are at the present 
time to be preferred. 

When a comparison with a normal thermometer cannot be made, 
an approximate determination may be made by taking the temperature 
in the axilla of a healthy person upon, say, six different days an hour 
after breakfast. A thermometer which is correct in its reading must 
then give an average reading of 37° C. or a little less (Liebermeister). 

Instruments with cylindrical bulbs are to be preferred to those with 
spherical ones. Thermometers are made so that by a prismatic form 
of the front surface the column of mercury appears broadened, magni- 
fied laterally, which greatly facilitates the reading of the index. Very 
small thermometers, from different reasons, are all of them unreHable. 

Maximal [self-registering] thermometers have a decided advantage, 
because it is not necessary to read them while the temperature is being 
taken. 

The temperature may be taken in the axilla, the rectum, or in the 
vagina. Taking the temperature in the mouth and also in freshly 
passed urine is to be avoided. The rectum and vagina are in reality 
the only places for an exact determination, because they are closed 
cavities within the body, and their temperature is uniform with that of 
the inside of the body. For this reason, and because they enclose the 
thermometer almost completely, they have also the secondary advan- 
tage that in them the mercury rises very quickly to its maximum. In 
the rectum or vagina most instruments record the temperature of the 
body within five minutes. But, unfortunately, in a majority of cases, 
for reasons of delicacy, the taking of the temperature in these places 
cannot be practised. But if the rectum be chosen, the oiled instrument 
is introduced to the depth of about five centimeters and left for five 
minutes. If there happen to be hard feces in the rectum, it is necessary 

^ See below. 



52 MEDICAL DIAGNOSIS. 

to remove these first, because experience has taught that in such a case 
the record of the temperature is too low. 

The axilla is not a perfectly closed cavity, but becomes a closed 
cavity only after the upper arm is pressed against the chest-wall when 
it begins to take the temperature of the body, but it almost never 
completely reaches it. On the contrary, the temperature here always 
remains a little below that of the inside of the body. In every case 
this is a few tenths of a degree lower, but in very thin subjects, where 
the cavity closes imperfectly round the thermometer, it remains much 
below the temperature of the inside of the body. 

The time required for the skin of the axilla and the instrument to 
reach the maximum temperature varies greatly, especially in collapsed 
patients with a cool surface of body and if bathed in perspiration. It 
is therefore necessary always first to wipe the axilla dry. Generally 
the maximum temperature is reached in ten to fifteen minutes. The 
best way is to look at the index after eight to ten minutes without 
moving the thermometer from its position, and to examine it again 
after ten to twelve minutes, to see whether the mercury is still rising. 
Care has to be taken to carefully place the bulb in the axillary cavity 
and to keep the upper arm closely against the chest-wall while the 
thermometer is in place. 

From what has been said, it is evident that the so-called minute 
thermometers, apart from their inexactness, are of no use for taking 
the temperature in the axilla, since the axilla itself does not reach the 
temperature of the body in so short a time. 

Generally one has to be content with taking the temperature in the 
axilla, and, as a rule, no important error is made if he considers the 
temperature taken in this manner as the temperature of the body. On 
the other hand, if one measures the temperature in the rectum and 
axilla alternately, it is well to add in the former case about two-tenths 
of a degree [two-fifths of a degree Fahrenheit]. 

From what has been said above, in collapsed and greatly emaciated 
patients one should occasionally at least make a controlling measure- 
ment in the rectum or vagina. In such cases I have not infrequently 
found that the temperature in the axilla, in spite of the greatest care in 
taking it, was one degree [Cent.] or more too low, even after the ther- 
mometer had been in the axilla a quarter of an hour. But in children 
and in unruly patients the rectal measurement is always to be preferred. 
In these cases one has particularly to look out that they remain quiet, 
lest the thermometer be broken. 

[Practical experience teaches that the best place to take the tempera- 
ture varies in different cases and subjects. In the case of children and 
infants the rectum is the best place. This is also true of many adults 
who are violent or restless, and likewise very aged persons. If the 
patient is conscious and quiet, it is much more convenient and also 
more reliable during a series of observations to take the temperature 
by placing the thermometer under the tongue, and directing and assist- 
ing the patient to keep the mouth tightly closed, with the instrument 
steadied in place by grasping it between the teeth. Thermometers of 
the best make are thoroughly reliable for reading after being in the 
mouth for three minutes. It is necessary to know whether the patient 



GENERAL EXAMINATION. 53 

» 
has recently been taking any very hot or very cold fluid or ice in the 
mouth. Apart from this source of error, the mouth is, on the whole, 
more uniformly reliable for temperature observations than the axilla, 
whose form and the conditions of the skin as regards moisture, etc., 
varies so greatly in different subjects.] 

If the thermometer is not self-registering, it must, of course, be 
read before it is removed. After using the thermometer in either the 
rectum or vagina it must, in every case, especially if there is the least 
suspicion of an infectious disease, be carefully disinfected. [No matter 
where the thermometer is used, it ought always to be immediately 
cleaned most thoroughly.] 

A single use of the thermometer may be of great value. But it is 
still more important, as will be shown below, to follow the state of the 
temperature progressively and to ascertain its course. For this pur- 
pose it is necessary to measure it at stated intervals. How frequently 
this must be done in of-der to ascertain the course of the temperature 
must be determined by the particular disease. The thermometer 
should be used at least twice in twenty-four hours (at about 8 A. M. 
and again at about 5 p. m.). In diseases with high fever, according 
to the rapidity with which the oscillations of the temperature are com- 
pleted, the thermometer must be used every three hours, every two 
hours, or even hourly. Where the changes of temperature are very 
marked it may be of interest to observe it every quarter-hour. It is to 
be understood that where it is proper to do so the use of the ther- 
mometer should, as far as possible, be suspended at night, in order not 
unnecessarily to disturb the patient's sleep. 

The record of the course of the temperature may be indicated by a 
curve. Charts suitable for this purpose of various kinds are to be had. 
They serve also for the record of the pulse and respiration. Nowa- 
days, in every case of severe fever the physician ought to prepare such 
a fever-curve. 

In what follows the statements regarding the temperature refer to 
measurements taken throughout in the axilla : 

2,, The Normal Temperature of the Body. — The average 
temperature is 37° C, and varies from this about 1.25° — from 36.25° 
to 37.5° C. 

The variations are of different kinds and have different causes. Of 
least interest, since they are only very insignificant, are those de- 
pendent upon age (in children, except the day after birth, a few tenths 
higher than later; in old people, again, a little higher); an elevation 
after meals ; an elevation after severe exertion. 

But the periodic daily variations are more important. They follow 
the following course : In early morning, between two and six, the 
" daily minimum " is reached, and then with considerable (not perfect) 
regularity it rises to the " daily maximum " between five and eight in 
the evening. From that point, during the night, it again declines. 
The difference between the minimum and maximum, the " daily differ- 
ence," is about 1° C. (in rare cases even nearly 2° C). 

After severe exertion the temperature rises quite a considerable 
amount higher, especially in the sun (Obernier observed that in the 
case of a person running it rose to 39.6° C.) and in very warm baths. 



54 MEDICAL DIAGNOSIS. 

3. Blevated Temperature ; Fever. — A great number of mor- 
bid conditions produce in man a temporary rise of temperature. Most 
of these diseases are of an infectious nature, but some of them are 
undoubtedly non-infectious ; for instance, certain diseases of the central 
nervous system, anemias and other conditions, can increase the tem- 
perature of the body. It has long been the custom to call every 
increase of temperature of the body a fever. But at the same time it 
has not been overlooked that in almost all febrile conditions, apart from 
the increase of the temperature, there are present still other phenomena 
which have been recognized as a complex of symptoms of fever. 
These phenomena are — a general feeling of illness, lassitude, sometimes 
graver disturbances of the functions of the brain, increased frequency 
of the pulse and respiration, with increased intake of oxygen and 
increased discharge of carbonic acid, want of appetite, thirst, disturb- 
ance of digestion. Frequently, in higher fever, there is decrease in the 
amount of urine and a relatively {i. e. in proportion to the amount of 
nourishment taken) increased discharge of the nitrogenous end- 
products of the metabolism of the body, particularly of urea and uric 
acid, as a sign of the destruction of the albumin of the body, and in 
high fever albuminuria. After the fever has continued for a certain 
time there are loss of weight and emaciation in consequence of the 
increased metabolism. 

The more exactly the febrile diseases have been examined, the more 
evident it has become that, besides the increase in temperature, to most 
of them also belong all, or almost all, of the above-mentioned phe- 
nomena, and furnish stronger reasons for the opinion that fever is a 
complex of processes and of symptoms, the only question being to 
which part of this complex the increase of temperature belongs. At 
the present day this question seems to be finally decided, contrary to 
the former opinion, that the increase in temperature is a partial phe- 
nomenon of the febrile state, which is co-ordinate with the other 
phenomena. 

It cannot be denied that some of the individual phenomena of the 
complex of febrile symptoms may occasionally be missing; for ex- 
ample, the acceleration of the pulse may occasionally be absent in 
the beginning of meningitis, or the acceleration is proportionally less, 
as in typhoid fever, or occasionally the disturbance of appetite does 
not take place in chronic febrile conditions, etc. But it is of especial 
significance that even the increase of temperature may be absent ; for 
example, in pneumonia in old people. But this circumstance ought 
not to give occasion to doubt that the symptoms of fever generally 
belong together. As a rule, this complex of symptoms always recurs, 
at least in infectious diseases, and we ought not to attempt to separate 
this complex of symptoms. The rise of temperature, therefore, is only 
a single phenomenon of the febrile state, but is very constant, and 
therefore often at once determines the judgment of the gravity of the 
disease. Hence it is well to continue to regard the increase of tempera- 
ture and fever as having the same value. Only the physician must 
never forget that he has before him a complex of phenomena, and that 
exceptionally the increase of temperature may not be present. 

The febrile temperature in itself shows a remarkable difference from 



GENERAL EXAMINATION. 55 

the normal temperature : it is more changeable — that is, it is quickly and 
considerably lowered and also increased by different external and inter- 
nal influences. This is in marked contrast with a healthy organism, 
which keeps a constant internal temperature with great tenacity. For 
instance, the febrile temperature increases if the patient is covered very 
warmly, if the temperature of the room is high, sometimes also after 
nourishment has been taken. Psychical influences, as fright and anger, 
have the same effect. On the other hand, the temperature becomes 
lower if the temperature of the room is low, markedly so from cool 
bathing, likewise when there is moderate loss of blood, as with the first 
menstruation or when there is internal hemorrhage. As regards the 
latter, the accompanying decrease of temperature can be of important 
significance in making an early diagnosis ; thus in typhoid fever we are 
to think of an intestinal hemorrhage when there occurs a sudden seem- 
ingly spontaneous fall of temperature. 

Height ctnd Form of Febrile Increase of Temperature. — With refer- 
ence to bodily temperature Wunderlich has prepared the following 
table : 

I. Normal temperature, 37° to 37.4° C. 
II. Subfebrile temperature, 37.5° to 38° C. 
III. Febrile temperature : 

{a) Slight fever, 38° to 38.4° C. ; 

{b) Moderate fever, 38.5° to 39° C. morning, and 39.5° C. 

evening ; ^ 
(c) Considerable fever, 39.5° C. morning, and 40.5° C. 

evening ; 
{d) High fever, 39.5° C. morning, and 40.5° C. evening. 

\_Comparison of Thermometric Scales. 

Cent. Fahr. 

34° 93-2° 

35 95 

36 96.8 

Normal temperature, 37 98.6 Normal temperature. 

38 100.4 

39 102.2 

40 104 

41 105.8 

42 107.6 

43 109.4.] 

If the temperature reaches 42° C, then we speak of hyperpyrexia, 
hyperpyretic fever. While the higher temperatures even of high fevers 
do not occasion direct danger to the organization, in hyperpyrexia the 
temperature is directly dangerous to life ; it generally leads to a fatal 
issue. 

In exceptional cases still higher temperatures have occasionally 
been recorded. For instance, temperature of 45° C. [113° F.] has 
often been observed. The " record " is probably held by the case 
reported by Teale where the temperature frequently rose to 50° C. 

^ Regarding this difference between morning and evening temperatures, see under 
Remission. 



56 MEDICAL DIAGNOSIS. 

[123° F.]. This was a case of lesion of the cervical part of the spine, 
which recovered. The injury to the spinal marrow was most probably 
the cause of the increase of temperature. 

The course of the temperature in twenty-four hours can vary much 
only in fever. Most fevers show distinct fluctuations, in that toward 
morning the temperature falls more or less {remission) until it reaches 
the daily minimum ; thence in the course of the day it rises {exacerba- 
tio7i)^ and toward evening reaches the daily maximum. The difference 
between the daily maximum and the daily minimum in fever is called, 
as in normal temperature, the daily difference. While the course of 
the temperature in fever is analogous to that of health, not unfrequently 
the minimum and maximum come at quite a different time ; as, for 
instance, the maximum may be at midday or at midnight ; a complete 
reverse may even take place, so that the maximum occurs in the morn- 
ing and the minimum in the evening (typus inversus^ ^ 

From this it is seen how the temperature must be exactly measured 
every hour of the day and night if it is of importance to know whether 
a patient has fever or not. There have been cases when the persons 
were thought to be without fever until the physician thought of ascer- 
taining the temperature at an unusual hour, as at night. 

The exacerbation of the fever is frequently connected with shivering. 
If the temperature rises very rapidly (it may rise several degrees in a 
single hour), generally there is a chill — that is, a decided feehng of 
chilliness, with severe shaking of the whole body and chattering of the 
teeth, where very soon, contrary to the subjective chill, there appears a 
high internal temperature. The skin is at first pale, livid, and generally 
cool ; toward the end of the chill, however, it is regularly very hot. 

On the other hand, the decrease of bodily heat is frequently accom- 
panied by perspiration. A rapid change in temperature seems in itself 
to be able to produce perspiration ; but specific toxical influences prob- 
ably play a part in certain diseases which are accompanied by frequent 
and abundant perspiration, as in tuberculosis and [acute] articular 
rheumatism. 

According to the amount of the daily difference we distinguish 
three types of fever : 

Continued fever : daily difference not more than i ° C. (chiefly high 
temperature). 

Remittent fever : daily difference over 1° C. 

Intermittent fever : maximum very high, minimum within the normal 
(or even below). 

4. The Subnormal Temperature. — It begins at 36.25° C. ; the 
lowest observed temperature is 22° C. 

I. It is observed in febrile diseases as an expression of two directly 
opposite conditions — namely : 

[a) In a sudden fall of the high fever with an advance to recovery, 
the " crisis," the critical decline of the fever. In this case the tem- 
perature falls during perspiration sometimes to below 34° C, and only 
in the course of one, two, or three days again returns to the normal. 
We recognize the " crisis " by the simultaneous diminution of the fre- 
quency of the pulse and the respiration, and the feeling of comfort and 
returning health by the patient. 



GENERAL EXAMINATION. 57 

{b) In the so-called collapse. In this condition there is generally a 
very rapid fall of the temperature, and at the same time a sudden 
failure of the heart, with (as is the contrary in " crisis ") increase of the 
frequency of the pulse, with paleness and general failure of strength. 
The condition of collapse may pass over, when there generally is an 
immediate rise of temperature again to the former point ; or it may 
pass on to a fatal termination. 

On the chart of the fever-curve the line of the falling temperature is 
crossed by the rising line of the pulse-curve in a characteristic way.^ 
Sometimes, in a case of collapse ending fatally, the pulse-line sinks 
parallel with the temperature-line.^ 

2. It occurs sometimes temporarily in severe hemorrhages, also 
sometimes, for a short time, in all kinds of chronic diseases, especially 
in those of the heart and the lungs. If the temperature suddenly falls, 
accompanied by weakness of the heart and general prostration, then 
also we speak of collapse. 

3. Continuing subnormal temperature, extending into a number of 
weeks, is very rare. It may exist in all severe wasting diseases and in 
diseases of the brain. 

5. Diagnostic Value of the Temperature, especially of its 
General Course. — If we eliminate an elevation of temperature due to 
bodily exertion or to being in heated surroundings [as in a hot room 
or hot bath], an increased temperature of the body is otherwise a cer- 
tain proof that a morbid state is present, and that it is one of those 
which produce fever. In this lies the first diagnostic value of a meas- 
urement of the temperature. Of this a few examples may be given : 

1. Frequently the elevated temperature, with some indistinctive 
complaints (or, in the case of children, abstinence from food with rest- 
lessness), is the only sign of a disease just commencing or of one that 
has been going on for some time. Ascertaining the temperature is, 
then, of deciding significance in that it leads to a more careful exami- 
nation and more extended observation and to directing suitable care of 
the patient. A high morning temperature generally points directly to 
an acute infectious disease. 

2. In marked cachexia, without distinct organic disease, the exist- 
ence of temporary fever indicates tuberculosis with considerable prob- 
ability. 

3. A single chill accompanied with a rise of the temperature to 
about 40° C. may, in a given case — say of a disease which from expe- 
rience sometimes causes suppuration — lead to the diagnosis of suppu- 
ration, as in gall-stones, renal calcuh, after injuries to the skull, as 
brain-abscess ; also here belongs puerperal fever, or, under certain 
circumstances, it may possibly be malaria. 

But the continued observation of the course of the temperature is 
of still greater importance. It advances medical knowledge in various 
ways : 

I. The course of the fever in a number of diseases is so typical that 
from the temperature alone the diagnosis may often be made with 
great probability, sometimes with certainty. At any rate, taken in asso- 
ciation with other symptoms, it is always an important aid in diagnosis. 

1 See Pulse. 2 See Pulse. 



58 



MEDICAL DIAGNOSIS. 



2. Moreover, during the progress of a febrile disease the tempera- 
ture not infrequently gives notice, by its unusual behavior, of the 



R. 



Day of disease : 
T. i 2 3 4 6 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 



80 180 41.0 

170 40.5 

70 160 40.0 

150 39.5 

GO 140 39.0 

130 38.5 

50 120 38.0 

110 37.5 

40 100 37.0 

90 36.5 

30 80 36.0 

70 35.5 

20 60 35.0 




Initial period. Acme. Amphibolic stage. Defervescence. 

Fig. I. — Fever-curve of a regular mild typhoid fever (Wunderlich). 



Day of disease : 
R. P. T. 4 6 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 "22 23 24 25 26 27 2$ 



SO 
70 


180 41.0 
170 40.5 
160 40 


I8B8EIIS8BIIIIIIIIIIIIIIII 


60 


150 39.5 
140 39.0 


IIIIUIIllilSIERRKIIIIIIII 


50 


130 38.5 
120 38.0 


||||||||||||j||||y[yyfiyyilSII 


dO 


110 37.5 
100 37 


IIEIIIIIBIIIIIIIIBIIlAlSI 


30 


90 36.5 
80 36.0 


BBBBBBIBBBBBBBBBBBBBBRBBI 


20 


70 35.5 
60 35.0 


IbbbbbIbbbbbbbbbbbbbbbbbI 



Fig. 2. — Typhoid fever : female, age 23. Fourteen days' continuous fever, then amphibolic 
stage of relatively longer duration. 



SO 



50 



150 39.5 



40 100 37. 



20 



Day of disease : 
T. "5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 29 30 31 32 33 34 35 36 37 

BHISBHHIII 

VnHIBBnbrii 
IBBHMnffiBIS8Si 

gnpnniHiiHafi 



40 41 42 45 



Fig. 3. — Typhoid fever, Wnh recurrence of fever. Servant, 23 years old. The interrupted line 
(see the arrows) indicates ten days' apyrexia. Rapid defervescence at the end. 

occurrence of an unusual event. Hence, not infrequently we first; 
become aware of an exacerbation or of a complication in a given dis-. 
ease by a specially high rise of the temperature. A sudden fall of the 



GENERAL EXAMINATION. 



59 



temperature may give notice of collapse, or a change to a fatal issue, 
or an internal hemorrhage, as of the bowels in typhoid fever. 

In the following the most important typical courses of fever are 
briefly set forth : 

I. Continued fever exists especially in two diseases, typhoid fever 
and croupous pneumonia ; also in typhus fever, sometimes in erysipelas 



Day of disease: 
T. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 R. P. 



isssBinssBKymi' 
sBmsiiBBSHimr 



Fig. 4. — Typhoid fever, slight, with tolerably severe recurrence of fever. Maiden, 10 years 

of age. 

and miliary tuberculosis. In a case of severe fever, with the diagnosis 
doubtful, a fever continued through several days points with proba- 
bility to typhoid fever, and next to acute miliary tuberculosis. 

In abdominal typhus [typhoid fever] the fever rises for several days 
by equal steps — "initial period;" reaches the summit, at which it 
remains as a continued fever one, two, or more weeks ; then, as a 







Day of disease : 


R. 


P. 

180 
170 


T. 

41.0 
40.5 


3 4 5 6 7 8 9 10 11 12 


80 


BRBIIimil 


70 


160 
150 


40.0 
39.5 


■iisiiiiii 


60 


140 
130 


39.0 

38.5 


lllllllltlBS 


50 


120 
110 


38.0 
37.5 


BBHiHIiSI 


40 


100 
90 


37.0 
36.5 


■HBIIillll 


80 


80 
70 
60 


36.0 
35.5 
35.0 


BIIIIIIIH 



Fig. s. 



-Fatal uncomplicated typhoid fever. Temperature and pulse cross each other. 
Female, age 37. 



rule, it gradually becomes a remittent fever of such a character that at 
first the daily maximum remains high, with the minimum going lower 
(" the double stage " ['* the long-continued paroxysm "] — the mini- 
mum may even go below the normal) ; then the defervescence begins, 
the maximum declining ; this usually reaches the normal in a few 
days. The remittent and defervescent stages may be protracted for 



6o 



MEDICAL DIAGNOSIS. 



some time, even as much as a week — " slow typhus." Moreover, the 
temperature may, after it has somewhat declined, again rise : *' recur- 
rence ; " or the disease, after the temperature has reached the normal, 
may begin anew, in the same manner as at first : " renewing " (see 
regarding these points Figs, i and 2). 

There are all manner of variations from this behavior of the tem- 
perature in typhoid fever, so that a single case seldom really pursues a 




Typhoid fever with abortion (see arrow). Age 25. 



typical course. Particular variations partly declare themselves by the 
changeable character of the febrile temperature, which was mentioned 
on page 55 ; but the fever-curve will especially be affected by the 
administration of antipyretics.^ But, particularly, every exacerbation of 



R. 


P. 


T. 


90 

80 


200 
190 
180 


42.0 
41.5 
41.0 




170 


40.5 


70 


160 


40.0 




150 


39.5 


60 


140 


39.0 




130 


38.5 


50 


120 


38.0 




110 


37.5 


40 


100 


37.0 




90 


36.5 


30 


80 


36.0 



Day of disease : 

10 11 12 13 14 15 16 17 18 19 20 23 24 25 26 27 




Fig. 7- 



-Typhoid fever (moderately severe) complicating lobar pneumonia on the eighteenth 
day. Collapse. Fatal. Female, age 2i. 



the temperature should cause the physician to think of complications 
(Fig. 7), and a fall of the temperature, of collapse (Fig. 5), and also of 
possible intestinal or other loss of blood (Fig. 6). 

^ The antipyretic treatment, especially with internal remedies, has no doubt the result of 
rendering the course of the fever untypical, and so destroying its diagnostic value. There- 
fore, until the diagnosis has been established in a case of febrile disease, the internal anti- 
pyretic treatment ought, if possible, to be suspended. 



GENERAL EXAMINATION. 



6i 



60 



50 



Day of disease : 

5 6 7 8 9 10 11 12 



In pneumonia (see Figs. 8 to ii) the temperature rises very rapidly 
(** initial period," lasting a few hours), often accompanied by chill, then 
remaining as a high continued fever. From this it may decline, also 
very rapidly — in a i^^ hours — to or below the normal, with a simul- 
taneous decline of the pulse and the respiration, and generally with 
severe sweating. Or the defervescence may be somewhat slower, 
occupying one or two days. The 
former way is called " crisis " (critical 
sweat), the latter " lysis " ; midway be- 
tween these two is " protracted crisis." 

Sometimes the day before the crisis 
the temperature suddenly falls very 
rapidly, and then again rises — *' pseudo- 
crisis " (distinguished from collapse by 
the pulse and the general condition, as 
referred to under " the subnormal tem- 
perature "). Or there is exacerbation 
of the temperature just before the crisis, 
rising from, say, 40° to 41° C. — " critical 
perturbation." 

2. Remittent fever is often met with 
(Figs. 12 and 13). It may exist some 

time during the course of any febrile disease. While the tempera- 
ture of continued fever is generally high — about 40° C. — the fever may 
remit, whatever its height. If the maxima are low, the minima 
may easily be normal — a behavior which, strictly speaking, must be 




20 

Fig. 8. — Croupous pneumonia, right 
lower lobe. Male, age 33. Continued 
fever. Crisis. 



R. P. 



80 



70 



50 



40 



20 



Day of disease : 
3 4 5 6 7 



10 



ISO 


41 




170 

IfiO 


40.5 
40 




150 
140 


39.5 
39.0 




130 
1?0 


38.5 
38.0 




110 

100 


37.5 
37.0 




90 

80 


36.5 
36.0 




70 
60 


35.5 
35.0 





Fig. 9. — Croupous pneumonia. 
Varnisher, age 39. 



Lysis. 



60 



50 



40 



30 



20 



P. 


T. 
41.0 
40.5 
40.0 
39.5 
39.0 
38.5 
38.0 


Day of disease : 
4*5 6 7 8 9 10 11 12 


180 
170 
160 
150 
140 
130 
120 


^^a^u^M^HABI Ki^S^^^H^Bi 



110 37.5 




Fig. 



10. — Pseudo-crisis in pneumonia. 
Male, age 25. 



considered as intermittent fever. Remittent fever belongs to a great 
variety of conditions, but especially to chronic tuberculosis. 

If the maximal points of the curve are high, the temperature often 
falls pretty rapidly, accompanied with chills and night-sweats {hectic 
fever). In tuberculosis of the lungs of long duration the continuous 
line of the evening temperature sometimes describes peculiar low (flat) 
arcs, which recur with a certain degree of regularity. According to 



62 



MEDICAL DIAGNOSIS. 



the observations of C. Turban, these circular lines also sometimes 
appear when a case of phthisis, which has been accompanied for some 



Day of disease : 
2 3 4 5 6 










40° 




40° 


39"^ 




39° 


38" 


38° 


37° 
36° 




37° 



Fig. II. — Pseudo-crisis and crisis 
in pneumonia (Wunderlich). 



namfflBasBiiBBBBBB 

IHHillinHO 

wammsm 



Fig. 12. — Remittent and intermittent fever in catarrhal 
pneumonia (Wunderlich). 



time by fever, is defervescing. The defervescence always takes a long 
series of weeks (compare Fig. 15). Turban supposes that cases of 



40° 



39° 



37° 



Bi: 



llBflVaBI 



ffjHin 



BBBn8liSBBHBIliBli.«B.ffMBiBnTlHlfJBWl 

■MBBB/WA^BMBBiaaUHUBIIIBIIBBHBBBH 
BBBBiWAWBfnViB.VABBllBBBBBIIIBllMBBBBaB 

SSi-Sa5«SS5SS5SISS55»iSaSiHM 



Fig. 13. — Hectic fever in tuberculosis of the lungs. 

phthisis which defervesce in circular (arc) lines are connected with an 
infection by streptococci. 



80 



70 



50 



40 




20 
Fig. 14. — Myelitis transversa. Pyemia caused by decubitus. Male, age 32. 

3. hitermittent fever, in a general sense, occurs in combination with 
remittent fever (see Fig. 12). The hectic fever mentioned above as 



GENERAL EXAMINATION. 



63 




accompanying remittent typhus [re- 
lapsing fever] is often also an inter- 
mittent, in which the minimum may 
even be subnormal. 

A peculiar form of intermittent fe- 
ver is observed in pyemia, where the 
temperature during chill may rise two, 
three, or more times in twenty-four 
hours, and soon fall, with sweat and 
great exhaustion, then again rising. 
The pulse is generally very frequent, 
and the patient often gives the im- 
pression, by the great prostration during 
the sweating stage, of going into col- 
lapse ; in fact, a condition of collapse 
sometimes exists with the fall of the 
temperature (see Figs. 14, 17). 




£Mf 



36^ 

Fig. 16.— rQuotidian in- 
termittent fever (Wunder- 
lich). 



In a narrower sense, however, we 
designate as intermittent fever the 
course of temperature of a special form 
of malaria. In this there is a continual 
alternation : between-times, without fe- 
ver (apyrexia) ; a quick, high rise, and, 
after a short time again, a rapid fall 
of temperature (often below normal) — 
" fever paroxysm." Severe chills and 
perspiration accompany these attacks 
of fever. The attacks recur with great 
regularity, either every twenty-four 
hours (quotidian), or forty-eight hours 
(tertian), or seventy-two hours (quar- 
tan). Sometimes the attacks recur one 
or more hours earlier on successive days (anticipating), or they may 
recur later each time (postponing). In these forms of fever the diag- 
nosis is made certain by the fever-curve (see Figs. 16, 18, 19). 



64 



MEDICAL DIAGNOSIS. 



4. Recurrent fever (Fig. 20) only exists as a renewal of a febrile 
disease or a disease known as relapsing fever. There is an attack of 
fever very like that of pneumonia, with sharp transitions and very 
severe sweating, the temperature falling often to 34° or 35° C, and 
apyrexia ; then a relapse after five to eight days, with a chill, followed 

Day of disease : 
R. P. T. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 




Fig. 17. — Cryptogenetic septico-pyemia, recovery. Female, age 44. 



by a high continued fever, which, in turn, ends in five or six days by a 
critical sweat, new apyrexia, fresh relapse ; and so over and over again, 
but each new attack with less fever and of shorter duration. 

5. Not infrequently a quite irregular fever will be met with. Its 
course is such that sometimes one cannot speak of any daily remission 



41° 



40° 



390 




finiili 



36° 

Fig. 18. — Tertian intermittent 
fever (Wunderlich), 




Fig. 19. — Quartan intermittent 
fever (Wunderlich). 



— at least, the lowest daily temperature comes at a variable hour of 
the day or night. But this fever may be of diagnostic value. In acute 
meningitis a continuing irregular movement of the temperature speaks 
against tuberculosis and against ordinary purulent meningitis, but, on 
the contrary, for epidemic cerebro-spinal meningitis. A pronounced 
irregular fever in an acute disease generally speaks against any of 
those diseases which manifest themselves by any typical fever. 



GENERA L EX A MINA TION. 



65 



6. I/Ocal Elevation or I/Owering of the Temperature. — 
1. Elevation of the Temperature. — In internal medicine this is seldom 
of diagnostic aid. We meet it where there is any kind of inflammation 
which is near the surface, as in surgery. In unilateral pneumonia also 
a careful measurement shows an elevation of the temperature in the 
axilla of the affected side. In recent paralysis of any sort the tempera- 



80 



mi 
w 



■ffi*" 



50 



40 



30 



20 



10 



Day of disease : 

P. T. 5 6 7 8 9 iO 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 

200 42.0 — -=-=-^^= 

190 41.5 

180 41.0 

170 40.5 

160 40.0 

150 39.5 

140 3C.0 

130 38.5 

120 38.0 

110 37.5 

100 37.0 

90 36.5 

80 36.0 

70 35.5 

60 35.0 

50 34.5 

40 34.0 



■HMIIiWllHH 

■nmiKiiiiHi 

■HHiHmUIIIH 

I 

mm 



nmimnHiii 
nmnmHH 
■mnmwM 




Fig. 2o.- 



-Febris recurrens, with only one relapse. 
Male, age 44. 



Arrow at a collapse-like crisis. 



ture of that side is somewhat higher for a short time ; then the tem- 
perature usually falls. Rare cases of hysteria exhibit a one-sided 
elevation of temperature with redness of the skin and perspiration. 

2. Lowering of the Temperature.— This is the expression of local 
disturbance of the circulation. In heart-failure, also in collapse and 
near-approaching death, the extremities and also the nose become 
cool. Coolness of the affected limb is observed in venous thrombosis, 
in paralysis of long standing in consequence of diminished venous 
blood-current, and in arterial embolism and thrombosis. 

6 



PART III. 
SPECIAL DIAGNOSIS, 



CHAPTER IV. 
EXAMINATION OF THE RESPIRATORY APPARATUS. 

EXAMINATION OF THE NOSE AND LARYNX. 

I. The Nose. — In making a local examination of the nose we 
employ Inspection and sometimes also Palpation. The inspection is 
external and internal : we look for asymmetry and other deformities 
and defects, and then at the shape of the nasal entrance [nostril] ; and 
also we note the quality of the secretions. 

Symptomatically, important anomalies of the nose are : uniformly 
swollen nose ; the thickening, however, is most marked at the en- 
trance (scrofulosis) ; ^ saddle-nose, caused by syphilitic periostitis, with 
exfoliation of pieces of bone. The syphilitic coryza (nasal catarrh) of 
the newly-born is associated with a peculiar snuffling sound.^ 

As regards the internal inspection, without the aid of instruments 
we can only examine the entrance into the nose. This only rarely 
shows characteristic alterations. For the inspection of the deeper parts 
a reflector and a nasal speculum are necessary. (See the paragraph in 
the Appendix upon Rhinoscopy.) 

To the semiology of the affections of the nose belong the following 
symptoms : foetor ex ore (ozena, ulcerations) ; occlusion, with respira- 
tion through the mouth, with obstruction of the nose or in the nasal 
cavity ; speaking through the nose occurs under the same conditions, 
but also when there is paralysis of the soft palate. This also occurs 
when there is an abnormal communication between the mouth and 
nose (cleft palate). Dilatation and motion of the wings of the nose 
occurs in dyspnea.^ 

Lastly, there is nose-bleeding [epistaxis], which is usually without 
any significance. But it may be caused by some severe local or general 
affection (tumors, aneurysm, deep ulcers, hemophilia, temporary hemor- 
rhagic disease). Nose-bleeding may be overlooked if it occur in deep 
sleep or in stupor (in acute infectious diseases), the blood flowing back- 
ward into the pharynx, through the esophagus, into the stomach. In 
this case there may be hematemesis, which may lead to an error in 
diagnosis. 

Acute muco-purulent and purulent catarrh of the nose is symp- 
tomatic in measles, diphtheria, and equinia. Chronic catarrh is a 
^ See below. ^ See below. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 6/ 

common symptom of scrofula (in which disease the whole nose is often 
swollen) and of syphilis. In the former disease there is sometimes an 
inflammatory thickening of the whole nose, particularly of its lower 
walls. Inflammation of an acute form, with very foul-smelling and 
ill-looking secretion, most frequently indicates diphtheria of the nose 
and pharynx. If it is chronic it may be due to catarrhal or specific 
ulcers. 

Among the conditions which particularly demand an examination 
of the nose, we mention acquired and hereditary syphilis, bronchial 
asthma, supraorbital neuralgia, hemicrania, certain affections of the 
eyes and ears. 

Regarding the further details upon the subjects of this paragraph 
we refer to the respective special works. As regards palpation of the 
posterior nares. see works upon Surgery. 

Palpation of the interior of the nose may be necessary (see works 
upon Surgery). 

2. The I/arynx. — The larynx is examined with reference to its 
functions (voice, cough, breathing) and the local appearances ; the 
latter include the external and internal examination.^ 

(a) Function. — The voice is changed in all affections of the larynx. 
It may be muffled, rough, hoarse, even to the entire loss of voice — 
" aphonia." In severe diseases it may have a whistling or sibilant 
(strident) quality : this indicates stenosis of the larynx ; or it is very 
hoarse and deep : this points to deep-seated ulceration. 

In diseases of the larynx the cough is hoarse, loud, or barking. In 
extensive destruction and in certain paralyses of the crico-arytenoid 
muscles cough is either more difficult or is impossible, since the power 
to close the glottis preceding the cough, as is normally the case, is 
wanting.^ 

Breathing is obstructed in all conditions that narrow the larynx, as 
in inflammation resulting in hypertrophy, in new formations, in scars 
with contraction. Then there is an inspiratory and expiratory dyspnea,^ 
and a peculiar noise of stenosis, " stridor laryngeus." In marked 
stenosis, especially when the thorax is flexible, as in children, there is a 
drawing in of the lower part of the thorax in front in the region of the 
insertion of the diaphragm.* 

Stenosis only in inspiration, causing inspiratory dyspnea, is ob- 
served in paralysis of the crico-arytenoid muscles, the dilators of the 
larynx. 

Laryngeal stenosis is distinguished from tracheal stenosis at the first 
glance in that in the former condition the larynx moves up and down 
simultaneously with each inspiration and expiration, and the neck is 
stretched to the fullest extent, while in the latter the larynx remains 
quiet and the head is often somewhat bent forward. 

{b) Local Examination. — The external examination is made with 
reference to pain, to deformities revealed to the sight or touch (these 
are very rare, resulting from destruction by periostitis), and laryngeal 
fremitus. 

Laryngeal fremitus is a trembHng of the thyroid cartilage during 

^ See also under Sputum. ^ See Cough. 

^ See Dyspnea. * See Anomalies of Respiration. 



6S SPECIAL DIAGNOSIS. 

Speech. It is stronger or weaker on one side in unilateral paralysis. 
It has no special diagnostic value. 

The Internal Examination. — By great care, and in the case of patients 
who have themselves under good control, sometimes the entrance to 
the larynx and the tissues even as far as the glottis can be touched. 
This method, however, has now little value, since it has been entirely 
superseded by the examination with the laryngeal mirror, which is the 
best means of examining the larynx.^ 

In inflammatory conditions patients complain of pain in speaking, 
but sometimes, even with severe disturbances, there is no pain ; now 
and then there is dyspnea, especially on exertion. Pai?i iji swallowing 
in chronic diseases of the larynx frequently indicates serious condi- 
tions — extension of new formation (carcinoma, tuberculosis) toward the 
esophagus or destructive suppuration. 

The leading symptomatic indicatio7is of diseases of the larynx with 
reference to other possible internal diseases are as follows : Acute 
laryngitis, with manifestations of an acute infectious disease, points 
especially to measles, croup, and also to small-pox ; in chronic laryn- 
gitis, tuberculosis, syphilis, or a purely local disease of the larynx may 
be present ; constriction by scars suggests, in the first place, syphilis, 
and also lupus. Of paralyses, paralysis of the recurrent nerve is of 
special diagnostic importance, since it often arises from pressure upon 
nerves, especially upon the left side from aneurysm of the aorta, carci- 
noma of the esophagus, tumors of all kinds in the mediastinum. Cer- 
tain paralyses indicate hysteria.^ 

EXAMINATION OF THE LUNGS. 
Topographical Anatomy of the Thorax. 

For locaHzing the surface of the chest with reference to height and 
depth we make use partly of anatomical prominences and partly (for 
determining the breadth) of certain local lines which we think of as 
drawn upon the surface of the thorax. 

Upon the front side of the thorax are the important anatomical 
regions : the fossa supraclavicularis (above the clavicle and bounded 
by the sterno-cleido-mastoid and trapezius muscles) and the fossa in- 
fraclavicularis. The latter has no distinct lower boundary. We under- 
stand it as the region immediately below the clavicle, about as far as 
to the second rib. From the second rib downward we designate the 
height by the ribs and intercostal spaces, as above the fourth, under 
the fourth rib, the fourth intercostal space. The number of the par- 
ticular rib is determined by counting from the second rib downward. 
It is always easy to find this rib : it is in articulation with the sternum 
exactly where the manubrium and corpus sterni unite, ordinarily form- 
ing a very slight angle (angulus Ludovici), and this place is plainly to 
be felt, and often seen, as a cross-Hne or prominence. We feel for this 
prominence and find the second rib to be its prolongation. We count 
the ribs from that downward, feeling obliquely outward as we go down. 
Morenheim's depression [the outer part of the infraclavicular depres- 

^ Regarding its use, see the Appendix. '-' See' below. 



EXAMINA TION OF THE RESPIRA TOR V APFARA TUS. 69 

sion] and the so-called Sibson's furrow (the under border of the pec- 
toralis major) are sometimes, although not very practically, useful as 
points for locating internal organs. 

For determining the breadth the vertical lines now to be mentioned 
are useful (the subject is supposed to be standing) : the middle line, 
drawn through the sternum ; the two sternal lines, drawn parallel 
along the sides of the sternum ; the mammillary lines, drawn through 
the male nipple ; and the parasternal lines, drawn midway between the 
sternal and the mammillary lines. 

On the two sides we determine the height by the ribs, which we 
count in front, and the breadth by the middle axillary line (drawn 
through the middle of the axilla, the arm being extended sidewise), 
the anterior and posterior axillary lines (drawn perpendicularly from 
the points where the pectoralis major and latissimus dorsi muscles 
leave the thorax, with the arm raised sidewise to the horizontal). 

Upon the back we name the fossa supraspinata ; above that, the 
suprascapular space, the fossa infraspinata, the interscapular space, 
between the two scapulae, the infrascapular space, under the shoulder- 
blades. Exact determination of height is made by counting the ribs, 
which, however, are difficult to count, especially in fat persons. They 
can be determined by three methods : 

[a) By counting the vertebral prominences from the vertebra 
prominens (the seventh cervical). 

{b) By counting from the lower angle of the scapula : this over- 
hangs the seventh rib in the average person when the shoulders hang 
comfortably and the arms rest against the chest with the forearms 
folded lightly. 

{c) By the point of the twelfth rib, which is easily felt (the best way 
for the lower ribs). 

Moreover, we have the scapular line, which is drawn upon the two 
sides of the spine through the lower angle of the scapulae (at the point 
already mentioned under (J?) ). 

It is to be observed that some of the vertical lines are not deter- 
mined exactly. This is true regarding the mammillary line (always 
very important) more than any other. In women it is generally very 
variable. On this account it is always to be thought of as drawn upon 
a male thorax. But even in the male the nipple is an uncertain point. 
By much practice the eye is cultivated so as to recognize what is to be 
regarded as the average location of the nipple in the male, and by this 
we must always correct the mammillary line. The various attempts to 
substitute other lines for this one have failed. 

The designation " infrascapular space " is little used. The expres- 
sions " right, left, behind, below," correspond to it, and are much to 
be recommended : behind or below the right, the left, scapula. 



The Anatomical Boundaries of the Lungs with Reference to the 

Thorax. 

In front the lungs reach to the sixth, and behind to the tenth, rib, 
and are almost everywhere directly in contact with the chest-wall. 



70 



SPECIAL DIAGNOSIS. 



They are not in contact with the chest-wall in the neighborhood of the 
heart nor behind a small portion of the upper part of the sternum. 

The accompanying figure exhibits the anatomical boundaries of the 
lungs. They project with their summits into the fossa clavicularis 
from 3 to 5 cm. above the clavicle, and with their inner anterior borders 
converging downward, so that behind the angulus Ludovici — not ex- 
actly behind the middle of the sternum, but a little to the left — they 
come to lie very closely to each other ; then they continue parallel 
downward to the insertion of the fourth rib. From there the inner 
border of the right lung proceeds still farther downward to the top of 
the insertion of the fifth rib, and then gradually bends toward the right, 




Fig. 21. — Position of the thoracic viscera, of the stomach, and of the hver, from in front. 
The portions of the heart and liver which are drawn with unbroken hatched Hnes represent the 
parietal portions of those organs. The portions that are not in contact with the chest-wall, 
but are covered by the lungs, are represented by broken (clear) hatched lines. 

The line e f, border of the right lung; g h, border of the left lung; dotted lines {....) a b and c d, 
the boundaries of the complementary pleural space; i, the boundary between the right upper and middle 
lobes; k, the boundary between the right middle and lower lobes of the lung; /, boundary between the left 
upper and lower lobes ; -w, greater curvature of the stomach (Weil-Luschka). 



SO that it follows along the sixth rib, on the upper border of which it 
meets the mammillary line. Then it continues approaching the hori- 
zontal (in the upright posture), so that in the middle axillary line it 
lies upon the seventh or eighth rib, in the scapular line upon the tenth 
rib (this location on the dead body is about i cm. higher than in quiet 
respiration in the living subject). On the left side the border of the 
lung bends sharply round from the fourth rib to give place to the 
heart, continues behind the fourth rib as far as the left parasternal line, 
then bends vertically downward, making a small bow which converges 
toward the right ; then, sharply bending again behind the sixth rib, so 



EXAMINA TION OF THE RESPIRA TOR V AFPARA TUS. 



71 



as to pass the mammillary line under the sixth rib (hence somewhat 
lower than on the right side), it passes the axillary line between the 
seventh and eighth, and the scapular line at the tenth, rib. 

The boundaries of the lungs are different according to age, as well 
as in individuals. (See section on Percussion of the Lungs.) 

The boundaries of the pleural sacs — that is, the lines on which the 
pleura costalis (sternalis) leaves the wall of the thorax and bends inward 
— agree in reality with the course of the inner borders of the lung. 
But along the lower borders of the lungs and at the cardiac concavity 
the pleural space extends considerably beyond the border of the lungs 
(in quiet breathing), making the sinus phrenico-costahs and the com- 




FlG. 22. — Position of the lungs, liver, spleen, and kidneys seen from behind. The liver and 
spleen are represented by the same hatching as in Fig. 21. 

a b, the lower border of the lungs; c d {. . . .}, complementary space; z (dotted line) (broken line)> 
border of the liver ; ey (dotted line), boundary between the upper and lower lobes of the lungs; ^, boundary 
between the upper and middle lobes of the right lung (Weil-Luschka). 



plementary pleural sinus. The size of these corresponds with the form. 
The largest is the complementary pleural sinus in the two axillary 
lines. This is there about lo cm. high. 

The pleural sinuses are therefore important, since into them extend 
the lungs at every deep inspiration, and also in the pathological, chronic 
inflation, emphysema pidmonum ; and also — because in them fluid 
effusions into the pleural cavity ordinarily first accumulate. 

The under surface of the lungs rests directly upon the diaphragm. 
The diaphragm in the dead body rises at its highest part, as a dome, 
about as high as the insertion of the fourth rib, a little higher upon the 
right than upon the left side. The average situation of the dome of 
the diaphragm in life, during quiet breathing, is a little lower. 



J 2 SPECIAL DIAGNOSIS. 

Finally, it is necessary to mention the course of the boundaries of 
the lobes of the lungs, since they sometimes have an important part in 
diagnosis : At the back, near the spine, the boundary between the 
upper and lower lobes is at the height of the lower angle of the 
scapula ; upon the left it gradually slopes forward and outward in such 
a way that in the axillary line it stands at the fourth rib, and meets the 
lower border of the lung (that is, at the sixth rib) in the mammillary 
line. On the right side the boundary-line divides near the outer 
border of the scapula into two diverging lines — the line between the 
upper and middle lobes and that between the middle and lower lobes. 
The former proceeds at first behind the third rib, and terminates at the 
inner border of the lung at the insertion of the fourth rib ; the latter 
meets the lower border of the lung somewhat within the mammillary 
line, and therefore behind the sixth rib. 

Hence, in front upon the right side we have the upper lobe about 
at the third intercostal space ; from there downward, really the middle 
lobe ; in front on the left side, for the whole distance, we really have 
the upper lobe ; on the right side we have the middle lobe above and 
the lower lobe below ; on the left side we have the lower lobe ; behind 
we have only the apices, formed by the upper lobes ; all the rest is 
lower lobe. 

Inspection of the Thorax. 

TJie examinatio7t of the tlwracic organs must always begiii with the 
inspection of the thoi^ax. Nothing is more faulty than to take up some 
other method of examination first. Inspection of the thorax is impor- 
tant because a very large number of the diseases of the lungs and 
pleura manifest themselves in the form of the chest-cavity and a 
change of the respiration. Certain diseases of the internal organs 
have a causal relation to changes in the form of the thorax. In other 
cases, as it appears, a given form of thorax accompanies a " disposi- 
tion " of the lungs to certain diseases (emphysema, phthisis). It is 
very probable, although it is difficult positively to establish, that some- 
times the thorax by its form either causes or favors the development 
of the given disease. Moreover, we know that there are deformities 
of the chest which in other ways injure or render useless the thoracic 
organs ; there are such also as have no influence upon the lungs or 
heart. 

Method of Procedure. — During inspection (as in all examinations of 
the thorax) attention must be given to having the patient straight, but 
without undue muscular tension. The light should fall symmetrically 
upon the front or back, whichever is under examination ; the eyes of 
the examiner should, if possible, be directly before the middle line of 
the body. The general structure of the thorax (and neck) should first 
be considered, next possible peculiarities, then the motions of respira- 
tion, first during quiet, then deeper, respiration. 

I. Normal Form of Thorax and Normal Respiration. — In 
a well-constructed thorax we expect, first, perfect symmetry. However, 
this is departed from almost always normally, in that there is a very 
slight curvature of the dorsal vertebrae toward the right. Moreover, 
the clavicular depressions may be only slightly indicated ; the angulus 



EXAMINATION OF THE RESPIRATORY APPARATUS. 73 

Ludovici [also called the angle of Louis] (the angle formed by the 
junction of the manubrium and corpus sterni) may just be recogniz- 
able ; the true ribs should so leave the sternum that from the top 
downward there is increasing obliquity, making the angle formed by 
the two opposite bendings of the ribs, " the epigastric angle," almost a 
right angle. The thorax should be well developed ; the scapulae in the 
upright position should lie flat upon it ; the intercostal spaces should 
be visible only at the lower ribs ; finally, the dimensions of the chest 
and the size of the body should have a certain relation to each other. 
Very seldom does the normal thorax correspond to this ideal, and 
there are many departures from it in persons who are perfectly sound. 
Some " physiological " departures may be mentioned : a slight asym- 
metry in a gradually-acquired spinal curvature or a deformity of the 
ribs, self-established ; further, a peculiar form of thorax, where the 
upper part is somewhat shallow, but the lower of increasing depth, so 
that the lower aperture of the thorax is very large ; also more marked 
angle of Louis (Braune) ; again, in a shorter thorax, a more obtuse 
epigastric angle may sometimes be observed in healthy persons (hence 
also without signs of emphysema).^ The supraclavicular depressions 
are often both deepened, with the apices of the lungs entirely normal 
(unequal deepening of them is, however, very suspicious of tubercu- 
losis) ; ^ single ribs, more frequently the second, third, also the fourth, 
on account of greater curvature sometimes project more in front ; on 
the other hand, the lower ribs will often be found pressed into the side 
and from there flattened forward ; and other variations. The boundary 
between the unsymmetrical and the pathological form of chest is much 
confused ; it can only be recognized in the individual case by attention 
to the location and function of the thoracic organs. 

Normal breathing takes place in this wise : inspiration only is active 
— that is, is accomplished by muscular action ; expiration, on the con- 
trary, is produced wholly by the elasticity of the lungs, the elasticity 
and the weight of the chest-wall, and the pressure of the abdominal 
organs upon the diaphragm. The number of respirations to the minute 
in the new-born is about 44 ; at five years, about 26 ; from the twen- 
tieth year, about 16 to 20. It is very easily influenced by a number of 
conditions : in sitting and standing it is somewhat higher than in lying ; 
it is increased by bodily activity and psychical impressions. Therefore 
it can only be determined during perfect quiet, with the attention with- 
drawn from the examiner, or during sleep. For counting it, it is 
generally most advantageous to lay the hand lightly upon the chest 
(or upon the epigastrium). 

The breathing is generally regular, and the single breaths are of 
equal strength ; but under the influence of the slightest psychical dis- 
turbance they easily become irregular and unequal. Many persons of 
sound health, as snorers in sleep, often breathe irregularly or unequally 
deep. Breathing is either exactly or very nearly symmetrical, though 
the left side frequently inclines to breathe a trifle stronger. 

The inspiratory enlargement of the tJiorax is occasioned by the ele- 
vation of the ribs and the sternum and the simultaneous drawing of the 
former upward and outward (intercostales externi and interni muscles 

1 See below. ^ See below. 



74 SPECIAL DIAGNOSIS. 

— '' costal breathing''^; moreover, by the contraction of the diaphragm, 
and hence flattening of its dome. The latter movement at the same 
time draws down the intestines, and so with every inspiration the 
whole anterior wall of the abdomen projects, but especially the epi- 
gastrium ('* diaphragmatic," or abdominal, breathing). The combina- 
tion of costal and diaphragmatic breathing varies in the two sexes : 
in the male the latter, and in the female the former, preponderates. 
But in aged females with firm thoracic walls diaphragmatic breath- 
ing increases ; while, on the other hand, male as well as female 
children incline to the costal type of breathing. From this it seems 
that the degree of flexibility of the thorax influences the kind of 
breathing. 

In the costal breathing of women, even in quiet respiration, the 
scaleni muscles (elevators of the first and second ribs) take a part, 
while in men these muscles belong to the auxiliary muscles of respi- 
ration.^ 

Diaphragmatic Phenomenon (Litten). — This peculiar and very strik- 
ing phenomenon can only be observed by keeping rather closely to the 
proceeding which the discoverer has indicated : 

The person to be examined should be undressed to the middle of 
the abdomen, and then should lie down as nearly as possible in a hori- 
zontal position, with the feet toward the hght. The room should be 
lighted only from one side. In the daytime, therefore, one should 
select a room with only one window, or, if there be more than one, all 
but one must be darkened. The patient is asked to breathe deeply, 
and the breathing must be diaphragmatic. The attention of the ob- 
server is directed to that part of the thorax which is below the fifth rib. 
The observer stands about one and a half to three steps from the side 
of the person examined or from a position midway between the side 
and feet. In most people, but not at all in stout persons, a shadow-like 
Hne ascends and descends with each respiration. This line is only 
present in the intercostal spaces, but as it crosses the ribs diagonally it 
appears in several intercostal spaces at the same time, and moves regu- 
larly up and down, and, in spite of the interruption by the ribs, it gives 
the impression of a continuous line. It is seen most distinctly near the 
anterior axillary line between the seventh and ninth ribs. In some 
people it can be followed from there far to the front and even round to 
the back. From the illumination necessary to observe this phenom- 
enon we conclude that the skin slopes toward the head. This sloping 
must of course be connected with diaphragmatic respiration or with the 
displacement of the edge of the lungs, the more so as it always coin- 
cides exactly with the boundary of the lungs as made out by percus- 
sion. The falling off of the surface of the skin taking place from below 
upward, as we have mentioned above, it is therefore probable that it 
corresponds, as Litten thinks, with the separation of the diaphragm 
from the wall of the thorax. It is impossible to see in this phenom- 
enon that portion of the edge of the lungs which goes down into the 
complementary space, for this would produce a slope from above 
downward. 

The value of the phenomenon for the diagnosis of the extent of 

^ See Auxiliary Respiratory Muscles. 



EXAMIIVATION OF THE RESPIRATORY APPARATUS. 75 

diaphragmatic respiration is, in my opinion, impaired by the fact that 
the phenomenon can be observed even in healthy people, frequently in 
only a small part — namely, that which is directed from above down- 
ward. There are not many cases in which it is seen moving up and 
down for six or seven centimeters, as is stated by Litten. If on one 
side the diaphragm does not move, and if the diaphragm is forced 
downward, the phenomenon will not be seen on that side, and conse- 
quently it is not observed in paralysis of the diaphragm and when there 
is considerable exudation and transudation of the pleura in pneumo- 
thorax, in pneumonia of the lower lobes, and also sometimes in sub- 
phrenic peritonitis. But it is well known that the last-named disease 
sometimes does not interfere with the contractions of the diaphragm, 
and in such a case the existence of the diaphragmatic phenomenon 
would decide the differential diagnosis against exudation in the pleura. 
But I have never yet seen such a case. 

^. Pathological Forms of Thorax. — {a) The Inflated or Em- 
physematous Thorax. — This refers to a chronic symmetrical expan- 
sion in all directions, conforming somewhat to the form of the chest 
during inspiration (the inspiratory position). The antero-posterior (the 
sterno-vertebral) diameter is increased. In many cases it appears as if 
the thorax became enlarged, especially at about the height of the mid- 
dle of the sternum, making a barrel-shaped chest ; however, this may 
be entirely wanting. The ribs are generally strong, and are at right 
angles to the sternum, hence the epigastric angle is larger than nor- 
mal ; the thorax is generally short. Frequently the angle of Louis is 
very prominent. 

The supraclavicular depressions may vary very much : sometimes 
they are deepened ; again, shallow or even projecting like pillows (the 
latter condition obtaining in emphysema of the upper part of the 
lungs). The lower intercostal spaces are sometimes drawn in during 
inspiration (inspiratory drawing-in).^ 

In the emphysematous thorax the breathing is so changed that the 
expiration is both slower and imperfect in consequence of the dimin- 
ished elasticity of the lungs ; it is prolonged, and in marked emphy- 
sema it is assisted by muscular action, especially by the transversalis 
abdominis and the quadratus lumlporum. We can then plainly see the 
abdominal wall energetically flattened, and we are directly impressed 
with the idea that the thorax 15 forcibly expanded. But the inspiration 
is also altered in consequence of the rigidity of the chest-wall ; ordinary 
costal breathing is wanting; it is very imperfect; and in its place we 
notice that the front of the chest, as a whole, has been drawn up by 
the powerful action of the sterno-cleido-mastoidei muscles. Conse- 
quently, in emphysema we have the breathing rendered difficult; in 
severe cases it may become so to a high degree.^ 

The typical emphysematous thorax points almost with certainty to 
emphysema, and hence its name ; however, we must guard against the 
mistake of calling every short chest an emphysematous one. On the 
contrary, also, we not infrequently find a general emphysema of the 
lungs in a chest that has no trace of the ** emphysematous " form. 
Active expiration, expiratory dyspnea, is much more characteristic 

1 See below, p. 87. ^ See Dyspnea. 



76 SPECIAL DIAGNOSIS. 

than the form of the thorax ; besides emphysema, it exists in no other 
condition except certain diseases of the larynx.^ 

[b) The Paralytic or Phthisical Thorax. — This is the direct oppo- 
site of the preceding : it is flat, especially in the upper part ; is often 
also narrow ; the intercostal spaces are wide ; the ribs are generally 
delicate, are sharply inclined downward from the sternum, and hence 
must be bent at a sharp angle again in order to come back to the 
vertebrae. This sloping from the sternum makes the epigastric angle 
very sharp ; the chest, as a whole, chiefly in consequence of the course 
of the ribs, is long. The angle of Louis is often very marked. The 
depressions are generally deep. The shoulder-blades frequently stand 
out like wings. 

Quiet breathing may be almost normal, but on exertion it is generally 
immediately very much increased in frequency ; it is shallow ; even in 
women the costal type is often wanting, especially at the upper part of 
the chest. 

This form of chest corresponds w4th that of tuberculosis. A well- 
marked paralytic thorax, except where phthisis of the lungs has early 
developed, is very infrequently seen ; but yet this disease occurs very 
often where the phthisical thorax is wholly absent — indeed, with an 
emphysematous thorax. In a paralytic thorax, with phthisis already 
developed, by means of the latter the form of the thorax and the 
breathing will become essentially and variously changed.^ 

But one must be very careful not to conclude that a thorax narrow 
from great emaciation, and especially one that appears flat, is a para- 
lytic one. For example, a beginner is apt to find that a patient conva- 
lescent from typhoid fever has a paralytic chest. Strictly speaking 
also, every plain or flattened thorax is not to be called a paralytic one. 
Moreover, emaciation and flattening of the upper parts of the chest in 
cases of developed phthisis frequently render the thorax paralytic, 
which it originally was not. 

{c) One-sided expansion of the thorax, a relatively infrequent 
affection, occurs in disease or functional loss of the opposite lung. The 
dilated side is then the seat of the so-called " vicarious emphysema" of 
the lung. This is distinguished from true emphysema by the absence 
of expiratory dyspnea. 

The dilated side is much more frequently the diseased one. The 
widening of the chest-cavity is more plainly seen from the front than 
from behind. Very frequently the mamma and the scapula are further 
removed from the median line than upon the normal side. The inter- 
costal spaces are level or are projecting ; in contrast with this, the dis- 
eased side drags after the other — that is, in inspiration it rises later and 
less than the sound side, and it may even not rise at all. Hence the 
spinal column is sometimes bent toward the diseased side. 

Marked expansion is met with in pneumothorax and in extensive 
pleuritic exudation, while the development of the latter usually first 
manifests itself by expansion and lagging behind at the posterior and 
lower part of the chest. A very slight expansion of one-half of the 
chest is, moreover, sometimes seen in croupous pneumonia of the 
whole of the affected lung. 

1 See Dyspnea. ^ See above under {a) and below under {d). 



EXAMINATION OF THE RESPIRATORY APPARATUS. // 

Circumscribed forward expansion of the chest occurs especially 
with tumors of the pleura, and is sometimes humped, and again 
uniform ; empyema which inclines to breaking through pushes the 
affected region prominently forward, and at the same time the skin is 
generally edematous. Encapsulated pleuritic exudations or circum- 
scribed pneumothorax seldom causes expansion, yet the first cause a 
smoothing out of the neighboring intercostal spaces, besides lagging 
behind. Local projections, moreover, sometimes occur from inflam- 
matory affections or neoplasms of the ribs or the subcutaneous cellular 
tissue. 

Local expajisions of tJie tJiorax are seen in cases of enlargement of 
other organs. The cardiac region may be bulged out in enlargement 
of the heart or distention of the pericardium;^ a marked enlargement 
of the liver may press out the lower ribs on the right side, and enlarge- 
ment of the spleen on the left ; and sometimes, especially in children, a 
very marked expansion of the whole lower part of the thorax, an en- 
largement of the lower aperture of the chest, is observed in cases of 
considerable expansion of the whole or the upper part of the abdomen 
(meteorismus, ascites, peritonitis, tumors). Then the upper part of the 
chest seems quite small in comparison with the lower part ; the whole 
trunk is hence shaped like a bee. From the drawing up of the dia- 
phragm there results interference with diaphragmatic breathing, and 
generally there is severe dyspnea. 

The extent to which the thoracic wall is driven forward, if caused 
by pleuritic exudation, depends to a large extent upon the degree of 
flexibility of the thorax. If the wall is soft, as is the case with chil- 
dren, the expansion is very pronounced ; if rigid, as in subjects of 
emphysema, sometimes a very large pleuritic exudate causes no 
noticeable expansion. Therefore, while we expect in general that an 
extensive pleuritic exudate will manifest itself by an enlargement of 
the affected side of the chest, yet where the walls are rigid we must not 
conclude from the absence of expansion that there is no exudate. 

id) Dra wing-in or Shrinking of One Side. — This is seen more or 
less frequently as a symmetrical drawing-in of the whole side, so that 
the affected side is altogether smaller than the other ; the ribs are close 
together, and in the lower part they may even overlap like shingles on 
a roof The shoulder of that side hangs down ; the mamma and 
scapula are nearer the median line. The spinal coluimi is curved with 
its convexity toward the healthy side ; hence the whole carriage is 
affected. There is diminished breathing or no breathing at all on the 
side drawn in ; on the healthy side there develops a vicarious emphy- 
sema. This condition is observed in recovery from extensive pleuritic 
exudations and in long-continued contraction of the lungs. 

In pleurisy it is the loss of elasticity and thickening of the pleura, 
with adhesions of pleural surfaces, in shrinking of the lungs, and the 
development of connective tissue in the lungs, which not alone hinder 
the lungs from following the inspiratory expansion of the thorax, but 
from the tendency to contract, as in scars of the skin, draws in the 
chest-wall. This inward traction, however, does not concern the 
thorax alone : the mediastinum, heart, and diaphragm are pulled 

^ See under Examination of the Heart. 



78 SPECIAL DIAGNOSIS. 

toward the sunken side. Hence there is displacement of the heart 
toward the diseased side and the diaphragm is high in the chest. 

More frequently there is an unequal degree or a partial shrinking 
on the affected side ; with it also is always connected a more or less 
marked lagging. It is most frequently observed above in front, here 
sometimes noticeable at the first commencem.ent as a deepening of the 
supraclavicular depression (an important symptom of contraction of 
the apex of the lung from tuberculosis). Again, a partial drawing-in 
is often seen, most frequently low down posteriorly, after the disap- 
pearance of a small pleuritic exudate. But there may be shrinking 
of any part of the chest-wall, as after gangrene or abscesses of the 
lungs. 

One must be careful not to confound a deformity of the chest from 
disease of the thoracic organs with deformities that are dependent on a 
primary bending of the spine and thorax. Concerning these see the 
following section. 

A repaired fracture of the ribs may also cause deformity ; a fracture 
of the clavicle which has healed with an angle forward may deepen 
the supra- and infraclavicular depressions, and so deceive one ; one- 
sided defect or atrophy of the pectoralis major of course flattens that 
side. All of these cases may be excluded by a more careful exami- 
nation. 

{e) Alterations of the Form of the Chest by Primary Deformity 
of the Skeleton. — Kyphosis, or bending backward, and scoliosis, the 
bending sidewise, of the spine, but, still more, the combination of both, 
kyphoscoliosis, sometimes occasion deformities of the chest that are enor- 
mous. Most frequently one side is smaller in front, while the other side 
appears to be enlarged ; and the picture of one-sided contraction of 
pleura or lung is more complete from the dragging-after of the smaller 
side. In consequence of a peculiar twist of the spine and its effect 
upon the course of the ribs the back is generally very crooked. This 
is spoken of more particularly in works upon surgery. The organs of 
the chest are almost always displaced from their normal position. The 
lungs are very much impaired in their function. Such patients become 
short-breathed on the slightest exertion. In diseases of the thoracic 
organs, and also in acute infectious diseases, these patients are exposed 
to greater risk than others. Whether in such cases we have to deal 
really with a primary deformity of the chest or with a contraction of 
the lung or pleura is generally made clear by the examination of the 
spine. Sometimes, however, a very careful examination of the skeleton 
and of the thoracic organs is necessary to answer this question ; and 
in some cases of long-existing deformity even this differential diagnosis 
may be impossible. The distinction of the different kinds of spinal 
curvature and their origin belongs to surgery. 

Rachitis is frequently the cause of such deformities, but it may also 
cause all other possible bendings of the chest. Of these, especially 
characteristic are — i. The rachitic chest, a thickening of the point of 
transition from the cartilage to the bony ribs. The several prominences 
arising from it form on both sides of the sternum a line passing as an 
arch outward and downward, 2. The pigeon-chest. The chest seems 
to be compressed sidewise and pressed forward. The ribs run sharply 



EXAMINATION OF THE RESPIRATORY APPARATUS. 



79 



backward from the front, so that the sternum stands forward Hke the 
keel of a ship, the sternovertebral measurement being much increased. 
3. A circular drawing-in in the neighborhood of the costal attachment of 
the diaphragm and above it. This retraction is in part directly pro- 
duced by the diaphragm, because the softened ribs do not offer suf- 
ficient resistance to its contractions. The retraction, however, partly 
results from the circumstance that the thorax sinks in just above the 
point of insertion of the diaphragm in consequence of the inspiratory 
lowering of the internal pressure. If dyspnea exists, and consequently 
increased action of the diaphragm, the retractions are increased. 

Funnel-breast (Fig. 23). — This deformity consists in a sinking-in of 




Fig. 23. — Funnel-breast (Ebstein). 

the sternum, especially of the lower portion of it ; it may be very con- 
siderable (as much as 7 cm.). The affection is generally congenital, 
and, according to our experience, in very marked cases it may prove a 
hindrance to respiration. Shoemakers' breast exhibits a sort of acquired 
funnel-breast, caused by pressure of tools against the lower part of the 
sternum and the xiphoid cartilage ; the depression never becomes very 
great, and involves only the cartilage ; it has no pathological signif- 
icance. 

According to recent experience, the funnel-breast sometimes is 
observed in several branches of a family. In individual cases it occurs 
as a sign of degeneration with other errors of development, or asso- 
ciated with neuropathic or psychopathic disease or hereditary taint. 

3. Anomalies of Respiration. — In the preceding section the 
anomalies of breathing which accompany the several pathological 
forms of thorax have been briefly referred to. But these require a 
further separate description. In giving this it will not be possible to 
avoid a partial repetition of what has already been said. 



80 SPECIAL DIAGNOSIS. 

ia) Anomalies of the Manner of Breathing. — The type of breath- 
ing which, as has been mentioned above, in the normal human being is 
typically different in the two sexes, and is denominated costal and 
costo-abdominal, may be influenced by a number of different path- 
ological conditions: 

1. The activity of the diaphragm, from some cause or other, may 
be restricted or entirely stopped ; it may then be replaced by increased 
thoracic breathing ; this causes the costal type peculiar to women to 
be still more prominent, while the male type is reversed ; instead of 
the abdominal predominating, the costal becomes predominant or 
entirely prevails — that is, may take on the female type. 

Such a restriction or prevention of the action of the diaphragm is 
occasioned by pain or mechanical restraint, or by weakness or paralysis 
of the diaphragm. Such is the action of all inflammations of the 
abdominal or pleural cavities in case they involve the corresponding 
serous covering of the diaphragm, markedly impairing diaphragmatic 
breathing. They often act so because they are painful ; but also some- 
times, especially in inflammation of the diaphragmatic peritoneum, 
actual paralysis of the diaphragm quickly develops, which is recog- 
nized by the entire disappearance of abdominal breathing.^ This takes 
place quite commonly in diffuse peritonitis ; it is, however, also some- 
times the only symptom of a beginning local *' subphrenic " peritonitis. 
Marked distention of the abdomen by tumors, fluid, and accumulations 
of gas in the intestines hinders diaphragmatic breathing in a high 
degree. Finally, there occurs paralysis of the diaphragm in organic 
diseases of the nervous system (bulbar paralysis, neuritis of the 
phrenic nerve in the various forms of multiple neuritis), as well as a 
manifestation of functional neurosis (hysteria). 

The action of the diaphragm is recognized, as has frequently been 
mentioned, by the protrusion of the epigastrium during inspiration. 
Of course this does not take place when there is no contraction. In 
complete paralysis the diaphragm is sometimes even completely sucked 
into the thorax; in hysteria, during inspiration, the epigastrium some- 
times sinks in extraordinarily deep. One-sided failure of action of the 
diaphragm may also occasionally be made out.^ 

2. But sometimes, also, hindered thoracic breathing may be replaced 
by increased diaphragmatic breathing ; hence in such a case, if the 
patient is a female, the type of breathing is changed — that is, abdominal 
breathing predominates instead of costal. 

Therefore, in very rigid thorax (emphysema), sometimes also in 
women, diaphragmatic breathing predominates. Here belong paralysis 
of the muscles of inspiration (bulbar paralysis) and myositis ossificans 
(rare), since the latter causes a rigid condition of the thorax. A disease 
of the skin at present well known, but rare, scleroderma, may, if located 
upon the thorax, also entirely abolish thoracic breathing. 

It has been shown above, under Emphysematous Thorax, how, in 
lieu of the peculiar costal breathing, this may in part be replaced by 
the movement of the thorax as a whole by the (auxiliary) muscles — 
the sterno-cleido-mastoidei."^ 

3. Asymmetry of breathing, which is occasioned as follows : the 
^ See p. 74. ^ See Palpation. ^ See below. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 8 1 

whole side or the upper or lower part of one side either (very rarely 
plainly) expands somewhat later than the opposite side or (most fre- 
quently) expands less strongly or not at all ; which condition has 
already been mentioned several times. 

Such a lagging may be caused by a unilateral painful affection of 
any kind ; moreover, by all diseases of the thoracic organs which inter- 
fere with respiration upon one side. This " lagging behind " is a valu- 
able symptom, especially in pJithisis (lagging in the infraclavicular 
depression), also in the beginning of pneumonia and pleurisy, when 
other symptoms are wanting.^ 

{b) Anomalies of Breathing as Regards Frequency and Rhythm. 
— Diminished frequency of breathing may take place in all severe dis- 
eases of the brain and its meninges, hence in large hemorrhages, 
tumors, etc. and in all forms of meningitis ; thereby exists always more 
or less dulness of intellect ; the slowness of breathing may sometimes 
pass into the Cheyne-Stokes respiration.^ Further, in acute infectious 
diseases with marked mental dulness the respiration may be slower ; 
finally, it is generally so in the death-agony. 

A very important form of diminished frequency of respiration is 
observed with stenosis of the upper air-passage ; this belongs in the 
section on Dyspnea. Increased frequency of respiration as a patho- 
logical manifestation belongs, without exception, to a large group, 
which will also be discussed in the next section. 

It has already been mentioned that we meet with temporary irregu- 
larity of breathing in healthy persons. It is of pathological, and gen- 
erally of grave, import in all cases of marked mental dulness (as in 
apoplectic, uremic, and the coma of severe typhus), and very especially 
in the death-agony. 

Forms of Periodic Respiration. — i. Cheyne-Stokes Respiration. — This 
is a kind of respiration in which, in pronounced cases, a group of 
respirations regularly alternates with a more or less prolonged pause 
of respiration, or apnea. The transition, however, from one state to the 
other is effected gradually, the period of respiration beginning and 
ending with shallow breathing. The patients, who in most cases are in 
a state of stupor, impress the observer by the circumstance that with 
regular pauses they make a few deep snorting or snoring, or perhaps 
sighing, respirations. If one observes a little closer, he sees that these 
deep respirations are followed by a few which become weaker and 
weaker, and then the respirations cease altogether. After a certain 
pause there is a short, scarcely perceptible respiration. This is followed 
immediately by a somewhat deeper one, and progressively the respira- 
tions become abnormal in depth, from which they slowly decline till a 
period of apnea is again reached. The pause in respiration may last a 
minute, and exceptionally even longer. [The translator recently 
observed a case following uremic convulsions in which the pause 
lasted ninety seconds.] The number of respirations in one period 
varies. Most frequently there are eight to twelve, which follow each 
other in about normal celerity, but at the beginning and end of the 
period of respiration they are sometimes somewhat slower. Occasion- 

^ See Palpation of the Thorax. 
2 See below. 



82 



SPECIAL DIAGNOSIS. 



ally there are, besides, some secondary symptoms : regular contraction 

of the pupils during apnea, and 
dilatation of them in the height 
of respiration ; retardation of the 
pulse during apnea ; isolated con- 
traction of muscles at the end of 
apnea. SahU has observed that 
patients become cyanotic at the 
beginning of respiration, and that 
the cyanosis increases till the 
height of the respiration is 
reached, which corresponds with 
the conduct of the pupils. Fi- 
nally, we and also others have 
here and there observed a peri- 
odic change in the state of con- 
sciousness corresponding exactly 
with the respiration : patients al- 
ready somewhat stupid become 
entirely unconscious during the 
period of apnea, and with the 
beginning and deepening of res- 
piration they regularly revive, 
look around, and even speak. 

Besides the perfect form of 
Cheyne-Stokes respiration, just 
described, there are also some 
less striking forms. It is not 
necessary that it comes to an 
audible deep breathing, or even 
to an abnormal depth of respi- 
ration ; or the period of apnea 
may be very short. The apnea 
may also be missing, in such a 
manner that only deep and more 
superficial breathing alternates, 
in regular periods, with a uni- 
form gradual transition. It seems 
to us that this also belongs to the 
Cheyne-Stokes form of respiration. 
This phenomenon is by no 
means rare, particularly if we in- 
clude the type of cases just de- 
scribed. It is principally observed 
in diseases of the brain, in severe 
disturbances of the circulation, and 
in toxical states. It occurs in 
meningitis with tumors of the 
brain, following cerebral hemor- 
rhages, etc., and in severe weakness of the heart following diseases 
of that organ, particularly in fatty degeneration (Stokes) ; then fre- 




EXAMINATION OF THE RESPIRATORY APPARATUS. 83 

quently in uremia, in cases of morphin-poisoning, in acute diffuse 
peritonitis, and, finally, in acute infectious diseases, particularly in 
typhoid fever. It is very seldom seen in persons suffering from 
slight forms of disease. There have been observed, however, traces 
of this anomaly of breathing during the sleep of healthy persons 
(Mosso). 

We have, on the contrary, almost always to do with patients 
severely ill, often with stupefied or unconscious ones. Sometimes 
patients breathe in this way only during an otherwise normal sleep, 
and then the symptom seems to have proportionally less signif- 
icance. Cheyne-Stokes respiration is frequently the precursor of the 
irregular, agonal respiration, and hence, from a diagnostic standpoint, 
it presages a bad turn. But still, that is by no means always the case, 
for, in the first place, it is sometimes observed for weeks and even 
months, especially during the sleep of persons suffering from heart and 
kidney disease. It also not seldom accompanies transitory toxical 
states, most frequently, in my experience, in uremia. The manner in 
which, and the circumstances under which, Cheyne-Stokes respiration 
occurs points to the supposition that its cause is in an alteration in the 
function of the respiratory center. Traube and others after him have 
attempted to find an explanation of the phenomenon. All these 
explanations result in the supposition of an alteration or diminution of 
the excitability of the respiratory center in the medulla oblongata, or in 
the supposition that the excitability of the oblongata becomes ex- 
hausted. But, in my opinion, no one has satisfactorily explained the 
peculiar periodicity of the respiration. When there certainly exists a 
diminution of excitability, and also a Hability of the ganglia of the 
oblongata to become exhausted, as occurs shortly before death from 
any cause whatever, we simply observe that the respirations become 
less frequent and more superficial. But no one has yet succeeded in 
explaining the pauses, and particularly the successive increase of the 
depth of breathing, in the beginning of respiration after the pauses. 

BioVs Respiration. — By this designation is understood periodic 
pauses in respiration, alternating with normal respirations more or 
less regular. The phenomenon, which is very rare, occurs most fre- 
quently in diseases of the brain, particularly in meningitis. The signif- 
icance of the symptom is the same as that of Cheyne-Stokes' respira- 
tion. Beyond this one may doubt whether this is not a sub-species of 
Cheyne-Stokes respiration, or whether it is a phenomenon which is 
different in principle from it. 

[c) Difficult Breathing, Dyspnea. — We have to designate that 
form of dyspnea as physiological which results when the respiratory 
center is supplied with blood which contains less than the normal 
quantity of O or an increased amount of CO2. In the clinic it is dif- 
ficult to give an absolute definition, because the perceptions of objective 
and subjective dyspnea (that is, which are only present in the sensa- 
tions of the patient), as well as the dyspnea with and without deficiency 
of oxygen or of blood overladen with carbonic acid, are much mixed. 
Generally the clinician speaks of objective dyspnea in the following 
cases : if the respiration is labored, whether the number of respirations 
be normal, or prolonged, or more frequent. Finally, in all cases of 



84 SPECIAL DIAGNOSIS. 

increased respiration, if rapid and labored breathing are combined, 
dyspnea is caused by all those conditions that interfere in any way with 
the exchange of gases in the lungs. ^ But there is another condition 
which manifests itself by an increased formation and giving off of CO2; 
that condition is fever. 

Labored respiration with normal or diminished frequency takes 
place in stenosis of the upper air-passage — that is, of the larynx and 
trachea. Intratracheal tumors, foreign bodies, inflammations (espe- 
cially croup), cicatricial strictures (generally syphilitic), granulations, 
also compression from without, and lastly paralyses of certain laryngeal 
muscles ^ which produce narrowing of the air-passage. The slow and 
labored respiration in these cases seems a perfectly inteUigible means 
of satisfying the requirements for oxygen, notwithstanding the fact that 
it is more difficult for air to enter. 

Strictly speaking, this form of dyspnea often occurs in diseases of 
the brain.^ At the acme of respiration in Cheyne-Stokes breathing we 
must speak, too, of there being dyspnea. 
Increased Frequency of Respiration Occurs — 

{a) In fever. Here it is often simply increased frequency, the 
breaths being deeper, but sometimes also we notice that they become 
somewhat labored (without its being a question of compHcation of the 
thoracic organs). The amount of quickening of the respiration varies 
very much according to the nature of the disease and with the indi- 
vidual. Nervous persons often breathe remarkably rapidly in fever; 
with children respirations as high as sixty or more to the minute have 
often been observed. Nevertheless, in fever every case of marked 
increase in frequency of breathing must lead to an especially careful 
examination of the thoracic organs. The cause of fever-dyspnea is, 
moreover, not alone the increased formation of CO.2, but is also the 
result of the irritation of the respiratory center by the warmer blood, 
as has been proved upon animals by an artificial increase of the tem- 
perature of the body. Finally, as a third cause of fever a direct effect 
of toxins upon the respiratory center is not excluded. 

Fever-dyspnea may be increased by association with that caused by 
diseases of the respiratory apparatus. 

{b) In all co7iditions that are connected with pain in breathing. 
Here belong all diseases of the pleura or of the lungs in connection with 
the pleura (especially croupous pneumonia), inflammatory affections of 
the diaphragm (trichinosis), of the peritoneum (especially the diaphrag- 
matic peritoneum), fracture of ribs, and severe rheumatism of the mus- 
cles of the thorax. 

Rightly to explain this form of dyspnea is often of the greatest 
therapeutic value ; it may sometimes (not always) be relieved by a 
narcotic. 

((f) In diseases of the bronchial tubes which narrow or close the 
tubes by the secretion or exudation. Here belong all forms of bron- 
chitis and also bronchial asthma. In the latter disease there is much 
less swelling and exudation than from bronchial spasm of neurotic 
origin, which chiefly causes the dyspnea. No doubt spasm of the 

^ See under Cyanosis. ^ See under Inspiratory Dyspnea. 

3 Also see page 81. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 85 

diaphragm is associated with this sometimes, which causes a prolonged 
inspiratory expansion of the lungs, and of course this increases the 
dyspnea. 

Where there are bronchial asthma and croupous bronchitis in addi- 
tion to laryngeal croup, there is generally very severe dyspnea with 
quicker and very forced respiration. Simple catarrh of the bronchial 
tubes generally leads to quickening of the respiration without the 
breaths being deeper; for a complete closure of the bronchial tubes 
cuts off a large section of lung, and so breathing is entirely lost in this 
section, as in capillary bronchitis, especially in children. The consid- 
eration of this condition properly belongs to the next section, in that it 
results in the lung-tissue itself becoming diseased. 

{d) In ail conditions in which the breathing surface of the lungs is 
diminished or the volumetric variation of the lungs, which is necessary 
for respiration, is disturbed. These are — 

All diseases of the lungs : the different forms of pneumonia, edema 
of the lungs, infarction, tuberculosis, emphysema (this not only on 
account of the diminished breathing surface, but also the loss of 
elasticity, and hence diminished contraction of the lungs during expira- 
tion) ; the different forms oi pleurisy with exudation, pneumothorax ; 
tumors in the cliest-cavity which diminish its capacity ; abdominal affec- 
tions which push up the diaphragm ; ^ marked kyphoscoliosis, with the 
resulting deformity of the chest and consequent unfavorable condition 
for breathing ; paralysis of the muscles of respiration ; and also tojiic 
and clonic spasm of the muscles of the chest, as in tetanus and epilepsy, 
which may occasion the most severe dyspnea. 

As is evident, these diseases differ widely from one another. Those 
that diminish the chest-cavity, if they are inconsiderable, sometimes 
merely restrict the inspiratory expansion of the chest, and so affect the 
lungs ; but if they are marked, then they directly compress the lungs 
and hence diminish their breathing-surface. 

It has been already stated that in a number of these conditions the 
need of oxygen may be met by a substitution of diaphragmatic breath- 
ing in place of the diminished costal breathing, and vice versa. It is, 
of course, very calamitous when there is a combination of several 
causes of dyspnea, as, for example, when a subject of kyphoscoliosis 
has an abdominal affection which presses up the diaphragm or has 
inflammation of the lungs. 

Accommodation, adaptation, plays an important part in many 
chronic diseases which occasion dyspnea. This becomes most strik- 
ingly evident if we compare the terrible dyspnea of beginning pneumo- 
thorax with the relatively comfortable condition of patients who have 
continually at their disposal for breathing only one lung or even only a 
part of a lung. In many of these cases it is easy to understand this 
accommodation — chronic cases, especially phthisical patients, who here 
come prominently into view, are generally anemic, and therefore 
require, at least when quiet, only a very small interchange of gases in 
the lungs ; but, nevertheless, every effort at muscular exertion imme- 
diately causes dyspnea. On the other hand, "lung-dyspnea" is gen- 
erally considerably increased by the fever which accompanies an acute 

^ See above. 



86 SPECIAL DIAGNOSIS. 

disease. Likewise, there are cases where we cannot dispense with the 
idea, which formerly was not clear, of an " accommodation." 

Dyspnea further occurs — 

{c) In diseases of the heart which cause stasis of blood in the lung- 
circulation. These are insufficiency or stenosis of the left auriculo- 
ventricular opening ; also heart-failure, which may occur in all diseases 
of the heart. 

Here the dyspnea is partly explained by the defective aeration of 
the blood in consequence of the slower circulation in the pulmonary 
capillaries. But that is not the chief factor, particularly in compensated 
mitral defects. The question here is regarding another element, which 
seems to have been made clear by von Basch. In consequence of the 
overfilling of the pulmonary vessels with blood the lungs are enlarged 
in volume, and they also contain more air, but at the expense of their 
elasticity. They become rigid — that is, they are capable of only slight 
alterations in their volume, similar to emphysematous lungs, but from 
an entirely different reason. This swelling and rigidity of the lungs, 
according to von Basch, gives the first satisfactory explanation of the 
peculiar dyspnea of compensated mitral defects. 

Increased and forced respiration. Forced respiration may at any 
time be associated with rapid breathing by increase of dyspnea. The 
only exceptions to this are those cases that arise from pain and paraly- 
sis, both from reasons that are easily intelligible. 

Mechanism of forced respiration. This is, in the most characteristic 
way, different from normal breathing — namely, that while the muscles 
of ordinary inspiration and the mechanical conditions of expiration no 
longer suffice, inspiration and expiration are assisted by the action of 
the auxiliary muscles of respiration. 

The auxiliary muscles of inspiration! are — the scaleni muscles in the 
male (in the female they act even in quiet breathing) as elevators of 
the first two ribs ; the sterno-mastoidei draw up the sternum when the 
head is fixed ; the pectoralis major and minor, the levatores costarum, 
the serratus post, super., all of which act as elevators of the ribs, the 
first named when the upper arms are fixed. In more severe dyspnea 
the trapezius, the levator scapulae, the rhomboideus are brought into 
action to elevate the scapula ; in severest dyspnea the extensors of the 
neck assist also, and then we notice the extension of the alae nasi;^ 
when the mouth is open the soft palate is seen to be drawn up during 
inspiration ; and, finally, even those muscles that dilate the mouth and 
depress the larynx may be brought into action. 

The muscles have very varying degrees of importance, the greatest 
being the work of lifting up the ribs, the sternum, and the shoulders. 
The expansion of the alse nasi as a symptom is not unimportant, but 
really does not at all assist in breathing. 

In expiration the following muscles act in assisting respiration : Of 
first importance are the broad muscles of the abdomen, especially the 
transversalis, which compress the abdominal contents, thus pressing up 
the diaphragm ; further, the quadratus lumborum and serratus post, 
infer., which draw down the lower ribs. 

It is easy to distinguish at a glance the moderate drawing-in of the 

^ See under Nose. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 8/ 

thorax and epigastrium which occurs in normal passive expiration from 
the active expiration of dyspnea, by the energy of the act in conse- 
quence of muscular contraction. Moreover, the contraction of the 
broad muscles of the abdomen is plainly to be seen. 

Patients yN\\h forced respiration exhibit still other appearances which 
partly stand in direct relation to the increased energy of the breathing. 

That the thorax may be entirely easy and that the auxiliary mus- 
cles may be able to act better, patients prefer the upright posture to 
lying down.^ Indeed, in very severe dyspnea they may not be able to 
lie down at all ; the arms are steadied, in order that the upper arms and 
shoulders may furnish a fixed point for the auxiliary muscles ; and in 
order that the sterno-cleido-mastoidei may act most efficiently in 
assisting respiration the neck is stretched and the face somewhat 
elevated. 

Not infrequently the breathing is audible ; in forced respiration it is 
panting, groaning. In stenosis of the larynx or trachea we hear the 
before-mentioned hissing — stridor laryngeus vel tracJiealis. The voice 
is weak, often suppressed ; the patient speaks with short, unnatural 
pauses — interrupted or broken speech. 

Here belongs the so-called inspiratory " drawing-in." Even in 
healthy people we sometimes notice with forced respiration that the 
lower intercostal spaces in the beginning of inspiration sink in some- 
what, instead of, as in healthy persons, a simple flattening-out from 
the contraction of the intercostal muscles. Drawing-in that is more 
marked and is prolonged during the whole of inspiration under all 
circumstances is pathological ; with the very yielding thorax of chil- 
dren even the ribs and the lower part of the sternum may share in the 
condition. It shows that the lungs do not follow the motion of the 
thorax — that, therefore, the air is prevented from entering the alveoli. 

Hence, all forms of stenosis of the larynx, of the trachea, and like- 
wise the rare stenoses of the two primary bronchi, cause inspiratory 
drawing-in on both sides, most markedly of the lower part of the 
sternum, the lower ribs, and intercostal spaces ; if the stenosis is very 
marked, the condition is extended to the upper ribs and intercostal 
spaces as far as the jugular and supraclavicular spaces. But stenosis 
of only one bronchus causes inspiratory drawing-in of one side when the 
breathing has a certain degree of force, besides ** lagging " of the 
affected side. Broiichitis of the smaller tubes, especially in children, 
may occasion inspiratory drawing-in in a more circumscribed way, as 
only the lower part upon one side. But we may also sometimes see 
an extended, very marked drawing-in with extensive capillary bron- 
chitis (with atelectasis, broncho-pneumonia) in children. 

As regards frequency, laryngeal croup and capillary bronchitis in 
children take first place among the causes of inspiratory drawing-in. 

There are two reasons why stenosis of the upper air-passage causes 
the drawing-in to be greatest at the lower part of the chest, and which 
may also affect the ribs of this part : first, the air entering the lungs 
reaches the lowest part, as being the farthest removed, last ; secondly, 
if the thorax is yielding, it is drawn in by the contraction of the dia- 
phragm, for if the diaphragm cannot descend when it contracts, since 

^ See Orthopnea, p. 29. 



88 SPECIAL DIAGNOSIS. 

the lung does not follow it, then the dome of the diaphragm becomes 
a fixed point, and the thorax in the neighborhood of the insertion of 
the diaphragm is drawn inward and upward. Moreover, the lateral 
region of the thorax above the insertion of the diaphragm sinks in so 
much because the thorax is softest, and also because there is frequently 
here the greatest difference between the external and internal pressure. 
Also, expiratory bulging sometimes takes place in the supraclavic- 
ular depression,^ especially in marked emphysema of the upper part of 
the lung, as, for example, after whooping-cough ; or in the upper 
intercostal spaces when large cavities are adherent to the chest-wall, 
as in pulmonary phthisis. With this condition there is a strongly- 
marked pressure in the thorax ; hence it is observed only in very 
forced expiration, and especially in strained coughing. 

Very frequently we find in cases of lung-cavities with expiratory 
bulging — especially frequent in the second intercostal space — the 
affected intercostal muscles very much shrunken, sometimes fatty 
degeneration of them. 

Finally, the picture of such an unfortunate will be completed by 
the expression of subjective anxiety, sometimes of the most fearful 
agony ; by the peculiar expression of the eyes, which is caused by the 
dilatation of the pupils which usually accompanies dyspnea, with occa- 
sional protrusion of the eyeballs ; ^ by the cyanosis and frequent cold 
sweat ^ 

According as inspiration or expiration, or both, are difficult, or the 
auxihary muscles of respiration are brought into action, we distinguish 
an inspiratory (pure or preponderating), an expiratory (pure or pre- 
ponderating), a mixed dyspnea. 

Purely inspiratory dyspnea exists with paralysis of the posterior 
crico-arytenoid muscles (dilators of the glottis) : here expiration is 
free, since the escaping current of air presses the vocal bands apart ; 
on the other hand, the in-rushing air brings them in contact like valves, 
and hence inspiration may be hindered even to threatened suffoca- 
tion. Tumors ajid foreign bodies may, moreover, be sometimes so 
located as, by valve-like closure, almost completely to preclude inspi- 
ration. Further, inspiratory dyspnea occurs with increased activity of 
other muscles when certain respiratory muscles are paralyzed* (as, for 
example, in paralysis of the diaphragm there is increased thoracic 
breathing, with co-operation of the auxiliary muscles). 

Purely expiratory dyspnea is observed with movable tumors situated 
below the glottis : the outgoing air pushes them against the rima glot- 
tidis, but in expiration they are drawn to one side. 

Moreover, a preponderating expiratory dyspnea is peculiar to bron- 
chial asthma (in addition to the always present inspiratory). Probably 
we correctly assume that the smallest tubes, spasmodically narrowed, 
are still more compressed by the pressure in the thorax during expi- 
ration. 

The disease that most frequently causes expiratory dyspnea is 
emphysema of the substance of the lungs ; the diminished power of 
expiration is chiefly from the diminished elasticity of the lung-tissue, 
the contracting force of the lungs ; generally there is, besides, dimin- 

1 See p. 68. ' See Nervous System. ^ q.v. * See p. 85. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 89 

ished thoracic breathing, since, if the thorax be too rigid to expand 
during inspiration, then it is also not contracted either by virtue of its 
own elasticity or the traction of the lungs. 

Bronchial astJnna of long duration always causes emphysema of 
the lungs ; then, of course, there is a twofold cause of expiratory 
dyspnea. 

In genuine emphysema of the lungs there is always also well-marked 
inspiratory dyspnea on account of the atrophy of lung-tissue and 
capillaries of the lung, and hence diminished breathing-surface. More- 
over, it will be understood that whenever there is expiratory dyspnea, 
if the difficulty of expiration is not equalized by forced or prolonged 
expiration, there must result a simultaneous inspiratory dyspnea; 
there is a diminished interchange of gases in the lungs resulting from 
the incompleteness of the act of expiration ; there is a demand for 
oxygen, and hence forced inspiration. There is no expiratory dyspnea 
with vicarious emphysema of the lungs. 

Mixed dyspnea — that is where it is manifest in equal degree in 
inspiration and expiration — is by far the most frequent. It accom- 
panies all the diseases of the respiratory organs not mentioned here ; 
also diseases of the heart, and fever. 

Palpation of the Thorax. 

This method of examination has, on the one hand, an independent 
value, and on the other it confirms, and with sufficient practice even 
adds to, the results of inspection. It is, therefore, very wrong to omit 
it. It is indispensable on account of its simplicity, and because, hke 
inspection, it quickly furnishes a result in a general way ; moreover, its 
result is often decisive in differential diagnosis, in a certain direction, 
relative to vocal fremitus. 

Palpation of the thorax with reference to the respiratory organs is 
made for the purpose of ascertaining — 

1. Possible pain upon pressure. 

2. The respiratory movements of the thorax, especially as to 

symmetry. 

3. Any friction-sounds or rales that may be felt. 

4. Vocal fremitus. 

In addition, there are some rare conditions that are not unimpor- 
tant in differential diagnosis. 

The examination with reference to the first and second points may 
be combined with inspection ; the trial of the third point may suitably 
be settled during auscultation, either before or after. Ordinarily, we 
test the vocal fremitus after the completion of percussion and auscul- 
tation ; hence we conclude the physical examination of the thoracic 
organs by noticing the vocal fremitus. 

We pause here in the course of the examination, and only speak of 
the first and second points ; the two others will be introduced under 
the heads of Percussion and Auscultation. 

I. Pain caused by Pressure upon the Thorax. — In diseases 
of the chest pain is common, accompanying the diseases or elicited by 
pressure. In case it really refers to an internal organ, and not to the 



90 



SPECIAL DIAGNOSIS. 



chest-wall, it indicates disease of the pleura or complication with the 
pleura. By carefully feeling the intercostal spaces with the tips of the 
fingers the region that is tender on pressure may be very exactly 
defined ; it is generally less extensive than the territory of spontaneous 
pain, since the latter ordinarily " radiates." 

This tenderness sometimes exists w4th exudative pleuritis, but in 
this disease it is often wanting ; more frequently it is seen in croupous 
pneumonia which also involves the pleura, and also in phthisis. In the 
latter disease it generally depends upon callous thickening of the 
pleura. 

It is very important, but also frequently difficult, to distinguish 
between pleuritic pains produced by pressure from those arising in the 
soft parts of tJic cJicst-zvall or the ribs. Phlegmonous inflammations 
and abscesses of the chest are, of course, easily recognized. Pain pro- 
ceeding from a rib is generally characteristic : quite circumscribed, it 
occurs only when pressure is made upon the affected rib (caries, perios- 
titis, over fractured ribs, slight pressure) ; also, rheumatism of the 
chest-muscles occasions no great difficulty, at least when it is in the 
superficial muscles : the muscle is ordinarily sensitive if pressed 
between two fingers. On the other hand, it is often not easy to dis- 
tinguish between pleuritic pain and intercostal neuralgia ; the latter can 
sometimes be distinguished by Valleix's points of tenderness, which 
stand wholly out of relation to deep breathing or cough.^ It is impor- 
tant to remember that neuralgic intercostal pain may be present in 
affections of the pleura, as in tubercular thickening of the pleura in the 
lower part of the thorax. 

In short, we ought, in the absence of other indications which point 
to a disease of the internal thoracic organs, to refer a pain produced by 
pressure upon the thorax rather to something else than to the pleura ; 
only continuous pain, always at the same places, over the upper sec- 
tions of the lungs, arising either spontaneously or from pressure, is 
suspicious ; this may indicate irritation of the pleura from tuberculosis 
of the apices. 

FractJires of the ribs are recognized by crepitation and by disloca- 
tion of the fragments ; also often by the fact that pressure at any part 
of the broken rib causes pain at the seat of fracture. Moreover, 
fracture of the rib may cause pleurisy. Caries of the rib may also 
excite pleurisy. Then in recognized pleurisy caries may be proved to 
be the cause by the circumscribed pain elicited by pressure upon the 
rib. 

It must also be mentioned that if a purulent pleuritis breaks outward 
{empyema necessitatis^ it causes peripleural inflammation, and with this 
there is pain upon the slightest pressure, besides swelling, redness, 
heat, edema of the skin, and, lastly, fluctuation. 

To the above-mentioned conditions revealed by palpation of the 
thorax must be added pulsations of the heart felt through a portion of 
infiltrated lung lying over the heart, and also in the so-called empyema 
pulsans (empyema pulsatile). This occurs when there is an accumula- 
tion of pus lying over the heart, almost always upon the left side, to 
which the pulsation of the heart is communicated. In some cases it is. 

^ See Nervous System. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 9 1 

very difficult to distinguish it from aneurysm of the aorta. It can only 
be done by taking a comprehensive view of the case. (We must be on 
our guard in puncturing or in making an exploratory puncture.) 
Sometimes pulsations are even found on the left lower posterior portion 
of the thorax. Usually several causes combine to produce the pulsa- 
tion : paresis of the intercostal muscles, higher pressure of the exudate, 
direct contact with the heart, lastly, as indispensably necessary, power- 
ful action of the heart. 

2. Testing the Movement during Respiration. — With special 
reference to symmetry, with some practice, palpation is a most excel- 
lent method. It gives more exact results than inspection, and makes 
the further examination easier, in that it directs the attention immedi- 
ately to the diseased side or the region of the thorax affected. 

The respiration is examined by placing the two hands alike upon 
the two sides of the chest. In order to test the breathing of the upper 
divisions of the lungs, place the hands flat in front, gradually diverging 
below, so that the tips of the fingers reach to the lower border of the 
clavicle. For examining the lower parts spread out the hands with 
the thumbs extended, so that the thumbs rest upon the angle of the 
ribs, and the fingers toward the sides of the thorax. Behind, only the 
respiration of the lower portion of the chest will be tested by laying 
the flattened hands, with the thumbs extended, upon the surface in 
such a way that the points of the fingers reach about to the middle 
axillary lines. 

For exact examination it is necessary, if possible, for the physician 
to be directly before or behind his patient ; the latter position espe- 
cially is often difficult when the patient sits in bed ; it is best, then, to 
have the patient slide somewhat down toward the foot of the bed. It 
must also be remarked that when the patient is lying down there is 
not infrequently produced a one-sided after-drawing in front and above 
by an imperceptible inequality in the position of the patient. It is, 
however, usually best to look out for this symptom in front above 
when the patient is in an upright position. 

When palpation is well performed, " lagging " over the apex in 
beginning phthisis or the " lagging " of the lower part of one side in 
pneumonia, pleurisy, infarction, etc. is recognized with great exactness. 
This is of great importance, because, as I have already said, '^ lagging " 
may be in many diseases for some time the only symptom. 

We may also test the contraction of the diaphragm with reference 
to its symmetry by palpation. We place the hands so that the finger- 
tips cover the epigastrium ; in this way may be detected the lack of 
contraction upon one side (^pleuritis diapJiraginatica, local peritonitis, 
unilateral paralysis of the phrenic nerve). Failure to contract upon 
both sides is, of course, seen at once.^ 

Benczur and Jonas ^ have lately tried to use certain differences in 
the temperature of different parts of the surface of the body for a sys- 
tematic demarcation of organs which lie against the parietes of the 
body, especially of the lungs, from parts which do not contain air. By 
passing the volar or dorsal surface of the fingers over the thorax they 
have found that the region over the lungs was always warmer, and 

^ Compare p. 74. 2 Deutsch. Archiv f. klin. Median, Bd. xlvi. 



92 SPECIAL DIAGNOSIS. 

they assert that by means of thermopalpation it is possible to make 
out exactly the line of demarcation between the lungs, heart, liver, 
etc., also from pleuritic exudations, and even to make out their relative 
dulness. That there are differences of temperature they prove by 
means of delicate methods of measuring. However, after having made 
a few experiments ourselves, we are obliged to deny the clinical useful- 
ness of thermopalpation, because the respective differences are too 
slight to be indubitably recognized by the finger. 

PERCUSSION OF THE THORAX. 
General and Preliminary Remarl<:s regarding Percussion.^ 

In daily life we learn on every hand that bodies of different physical 
structure give forth different sounds when struck. We also sometimes 
strike an object in order to determine from the sound it gives forth 
what its physical condition is — that is, whether it is hollow or solid. 
This is the principle upon which percussion is practised on the human 
body : from the sound elicited by the blow we judge of the physical 
condition of the part which lies beneath the covering of the body 
within the sphere of our percussion-stroke. 

Hence, percussion gives direct information regarding organs or 
parts of organs which lie approximately near to the surface of the 
body ; in general, by this method we penetrate only to the depth of 
5 or, at most, 7 cm. 

I. History and Methods. — The honor of the discovery of per- 
cussion belongs to a physician of Vienna named Auenbrugger; the 
paper in which he made known his method appeared in 1761 u^ider 
the title, Inventinn ?iovum ex percussione thoracis humani ut signo 
abstrusos interni pectoris morbos detegendi. For almost half a century 
Auenbrugger's discovery was, on the one hand, declared to be without 
importance, and, on the other, was ridiculed until the year 1808, when 
Corvisart, body-physician to Napoleon I., emphatically revived and 
largely improved it by a translation into French, with a commentary. 
Then the truth began really to prevail, especially by the influence of 
Piorry in France and Skoda in Vienna. The former was the founder 
of topographical percussion. During fifty years the method gradually 
became common professional property. Further, and up to the most 
recent time, it experienced improvement and explanation of every kind, 
especially by Wintrich, Traube, Biermer. Gerhardt, and Weil. For 
some time past, especially since the labors of Weil, it appears that a 
degree of certainty has been reached in regard to this proceeding. 

In the course of the development of percussion several methods of 
striking the body have been discovered, most of which still have value 
to-day. 

Auenbrugger struck directly upon the thorax with the tips of the 
fingers — direct or immediate percussion. 

Piorry discovered indirect or mediate percussion in that he placed 
under the percussing finger a small plate of ivory, a pleximeter. 

1 In this chapter the -author follows in many ways, but not entirely, the views and 
methods of presentation of Weil, whose well-known and excellent work has done much -to 
establish this subject upon an accepted basis. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 93 

Wintrich introduced the percussion-hammer, which had ah'eady 
been sometimes used by Laennec and Piorry, in place of striking with 
the fingers. 

But finally, in more recent times, the method of indirect percussion, 
without instruments, has very widely prevailed. The index or middle 
finger of the left hand is used as the pleximeter, which is placed upon 
the spot to be percussed, and it is struck with the index or middle 
finger of the right hand (finger-percussion). 

Of these methods, that of Auenbrugger, the direct, has been 
dropped as being less practical, while nowadays the three in use 
are all examples of the indirect method : 
I. Finger-percussion. 
II. Finger-pleximeter percussion. 
III. Hammer-pleximeter percussion. 

All three are practised and taught by good teachers of percussion ; 
all three, in reality, yield equally exact results ; the secret of their 
value lies in their application. The fact of the matter is that one who 
thoroughly understands finger-percussion can very quickly acquire a 
knowledge of the two other methods. Hence I am most heartily in 
accord with those who in their teachings and writings emphatically 
recommend their students at first to practise the finger method of per- 
cussion exclusively. 

I think it superfluous for me here to go into particulars regarding 
the tecJmiqiLe — these can only be made clear in the clinic — but I must 
remark that the greatest difficulty in finger-percussion is in holding 
the percussing finger crooked like a hammer, and at the same time 
having the wrist-joint move quite freely. Also, the numerous forms 
of percussion-hammers and pleximeters (the latter of glass, ivory, 
hard rubber, and wood in different forms) cannot be described here. 
It appears to me that the hammer with a wooden handle and a metal 
head, not too heavy, is rather to be recommended ; likewise, a medium- 
sized oblong ivory pleximeter, about 2 cm. wide, and the so-called 
double pleximeter of Seitz. Even to those who practise finger-percus- 
sion this last is recommended for percussing the supraclavicular 
depressions. 

There have lately been invented small thimble-like Coverings for the 
percussing finger to be used as a substitute for the hammer. They 
seem to us to be worthy of notice, though we have not yet had much 
experience with them. But after various trials we do not think it is 
practical to provide the finger that is used as a pleximeter with a 
rubber ring or anything of that sort. 

There is one point of great importance — that the individual should, 
as much as possible, be similar and uniform in his methods through- 
out : in percussing, if the finger method is used, he should always 
strike upon the index or always upon the middle finger of the left 
hand ; the pleximeter, if that is used, should always be used in 
exactly the same way, etc. Nothing is worse than frequently to 
change methods or instruments, be the change ever so slight. But 
if physicians, as is true of many, are accustomed ordinarily to percuss 
without an instrument, but at certain parts of the thorax where it is 
difficult to use finger-percussion they regularly employ a pleximeter 



94 SPECIAL DIAGNOSIS. 

or both pleximeter and hammer, there is no objection to this twofold 
method ; only the examiner must be master of the two methods which 
he employs. It is well also always to repeat the same method upon 
the same parts of the body. 

2. Qualities of Sounds. — By striking upon the body we cause 
a sound. This percussion-sound differs according to the condition of 
the part of the body which is shaken by our percussion-blow. From 
this fact there results directly two main points, which form the basis 
of the doctrine of percussion : 

I. When we strike upon a soHd portion of the body entirely free 
from air we elicit a toneless sound of the least possible intensity and 
duration ; it is designated as " absolutely deadened " or as a *' thigh 
sound," since it is like that caused by striking upon the thigh. [Dead- 
ness : I have frequently used this word and its derivations as giving a 
useful and accurate discrimination from the familiar English terms flat- 
ness, dulness. Deadness is more than dulness. — Translators^ 

II. If organs containing air lie in the range of our percussion-blow, 
then these give forth a sound of a certain intensity, duration, and 
tone ; this sound is designated as ** clear." 

The clear sound of organs containing air may have only a different 
degree of intensity or clearness. Its intensity depends upon — 

1. The length of the oscillation. It is therefore stronger the 
stronger the blow, and, moreover, the nearer the organ containing the 
air is to the percussing finger — that is to say, the less the percussion- 
stroke is weakened by the tissue, as fat, muscles, bones [also clothing], 
intervening between it and the air-cavity. 

2. By the volume of the parts of the air-containing tissue set in 
motion. 

Hence, with equal strength of percussion we have in different parts 
of the body different intensity and different clearness of sound accord- 
ing to the greater or less amount of air which the tissues contain, or 
according to the nearness or distance of the air-cavity from the surface 
of the body — that is, from the percussing finger. 

It is according to the change of these conditions in the human body 
that we obtain the different clear sounds : we may meet every grade 
from absolute deadness to a very clear — the pecuHarly clear — sound. 
These intervening grades are designated as " relative dulness " (that is, 
in comparison with a real clear sound it is dull). 

Absolutely dead or dull sounds differ according as they proceed 
from muscle, bone, etc. We cannot wholly ignore these difterences as 
if not existing. 

On the other hand, the clear sounds fall into the two following 
important divisions : 

I. Tympanitic sotind (the name is from tympanon ; the kettle-drum 
or tymbal, not exactly, but very nearly, produces it). This approaches 
a musical note, so that we can exactly define its place on the musical 
scale, and it is actually shown formed from regular oscillations in the 
rotating reflected image of the sensitive gas-flame. It possesses also, 
according to the different conditions to be described later, sharply 
definable differences of pitch. A tympanitic sound, such as is fre- 
quently met with in the body, can easily be produced if one strikes 



EXAMINATION OF THE RESPIRATORY APPARATUS. 



95 



upon his own cheeks which have been inflated, but not too strongly 
stretched. 

2. The clear sound called non-tympanitic, also more briefly *' lung- 
sound " — a very practical designation. This has no sound definable 
by its pitch, but yet it may be known in general as " high " or " deep." 

Hence, both the tympanitic and the non-tympanitic sounds have a 
certain intensity and duration ; but while the latter may be only 
approximatively designated as high or deep, the pitch of the tone 
brings it toward the tympanitic. Both occur in a very high degree of 
clearness and in all degrees of relative dulness ("relative dulness " or 
" dull tympanitic sound "), even to an often unnoticeable transition to 
absolute dulness. 

I. We give here and later on some schematic drawings which are 
designed to facilitate the understanding of the foregoing points. We 
can recommend the application of this manner of representation to 
teachers of percussion, as well as to the student for his private studies 
or for his notes of what he has seen and heard in the clinical courses. 

Percussion of the lungs is represented in a rough schematic draw- 
ing in which a long arrow signifies strong percussion, a short one weak 
percussion. In the first and third drawings the parietes, for the sake 
of simplicity, are represented as being of uniform thickness. The 
hatched triangles in each figure represents the portion of the lung 



Lung 





Lung 




Fig. 26. 



Fig. 27. 



Fig. 25.— Schematic representation of the difference between strong and weak percussion, 
the conditions being otherwise the same. The length of the arrow indicates the strength of the 
percussion, the size of the hatched triangle, the extent of lung-tissue affected by the percus- 
sion-blow, and also the intensity of the sound. 

Fig. 26. — Represents the different results, with equal percussion force, where the thick- 
ness of covering varies : clear sound ; relative dulness ; no sound — that is, absolute deadened 
sound. 

Fig. 27. — Represents the influence of the volumes of resonant body upon percussion : 
over the apex and border, on account of the small volume of lung : with equal and moderately 
strong percussion and equal thickness of covering, the sound is less intense than over other 
parts of the lung. 



which is set in vibration by the percussion-blow, and also the intensity 
of the sound. Figs. 25, 26, 27 show how the intensity of the sound is 
influenced 

(a) by percussion with different degrees of force, 

(d) by different thicknesses of the parietes, and 

(r) by the depth or volume of air contained in the organ. 



96 SPECIAL DIAGNOSIS. 

2. In the foregoing we give those designations which in late years 
we have without exception employed in our instruction on percussion. 
Regarding the large number of other terms for qualities of sound 
which the older teachers of percussion have introduced, but which, to 
the great advantage of clearness of mutual understanding, have more 
and more disappeared from the literature of the subject, we refer to the 
classical work by Weil on Topographical Percussion. We have in fact, 
as will be seen, followed the nomenclature proposed by Weil, with 
only one exception ; the term dull soimd is avoided, and in place of it 
we have employed the expression (which, it is true, is somewhat cir- 
cumstantial) " absolutely deadened sound," or " thigh-sound." This 
was done because, over and over, we found that pupils were reminded 
of the '' dull sound of the kettle-drum," " dull roaring," etc., and hence 
were confused — in short, because the expression does not grammati- 
cally designate what is intended in teaching percussion. '' Absolute 
deadened sound " is an expression which has this advantage — that to 
the beginner it is a new association of words ; it cannot, therefore, so 
easily occasion confusion. Moreover, the expression always summons 
one to a more exact testing as to whether, at the particular place, there 
is really absolute or only relative dulness, and also it seems to us pref- 
erable, for every teacher of percussion knows how much this is needed 
— that, for instance, in percussing the lower part of the right mammil- 
laiy line the so-called relative liver-dulness is spoken of as absolute 
deadness. 

3. For the sake of brevity and clearness we also have really not 
gone into the many ideas and the manner of explaining them presented 
by others on this subject, which was formerly quite confused, and is 
even yet difficult to master. But we cannot abstain from citing here, 
by reason of their historical interest, the three fundamental sentences 
from Skoda : 

{a) All fleshy parts not containing air (except tense membranes and 
filaments), also fluid accumulations, give an entirely dead and empty, 
scarcely distinguishable percussion-sound, which can be demonstrated 
by striking upon the thigh. 

{b) Only bones and cartilage when directly struck give a pecuhar 
sound. 

{c) Every sound which we elicit by percussing the thorax and abdo- 
men, and which differs from the sound of the thigh or bone, comes 
from air or gas in the chest or abdominal cavity. 

4. The acoustic character of the clear and that of the relative or 
absolutely dull sound is clearest expressed if we say : the dull sound is 
a very slight noise of short duration ; the clear, non-tympanitic sound 
is a noise louder and of longer duration, with a trace of being a note; 
this latter, however, is so little apparent that it either cannot at all be 
recognized, or only in general, as to its being high or deep. In the 
tympanitic sound, with the discordant mingling of tones, there pre- 
dominates a tone of such a character that it is plainly heard and its 
musical pitch distinguished. 

3. The Conditions that Determine the Quality of the 
Sounds and their Production in the Body. — The Feeling of 
Resistance. — The tympanitic sound exists — 



EXAMIXATION OF THE RESPIRATORY APPARATUS. 97 

1. Over cavities that contain air or gas if they are surrounded by 
walls moderately smooth and capable of reflexion, and if they com- 
municate with the external air through an opening ; the walls may be 
stiff or yielding. The intensity of the tympanitic sound thus produced 
depends upon the conditions (mentioned on page 94) influencing the 
intensity of clear sounds in general. The musical pitch of the sound is 
determined by — 

(a) The size of the communicating opening : the larger it is, the 
higher the tone; 

(b) The volume of the cavity containing the air : the larger the cavity, 
the deeper the tone; 

{c) If the walls are yielding, membranous, by their tension : lax 
membranous walls make the tone deeper. 

2. Over air-containing cavities with yielding, membranous walls if 
the cavities are closed — that is, do not communicate with the external 
air; only the walls, and with them the enclosed air, must not be too 
tense. Here the pitcJi is determined only — 

(a) By the volume of the air-cavity : see above under i . (U). 

{b) By the degree of tension of the wall : see above under i. (f). 

But if the tension of the wall (and with it the enclosed air) of a 
closed cavity reaches a certain degree, then the percussion-tone 
becomes clear and non-tympanitic. Likewise, cavities that are closed 
on all sides by stiff walls give a non-tympanitic sound. 

The tympanitic sound mentioned under i is called " open," that 
under 2 " closed." The former has a much more pronounced tympanitic 
character — that is, the pitch of the tone appears more distinctly — than 
the latter. 

When the cavities are cylindrical, communicating outward by an 
opening, the pitch of the tone is determined by the length of the 
cylinder : the longer it is, the higher the tone. Some experiments, 
illustrating what has been said, are easily performed and are strongly 
recommended to beginners : Take an empty Florence flask and percuss 
upon its mouth, either directly or hold the pleximeter lightly over its 
mouth ; then diminish the quantity of air by partly filling the bottle 
with water ; if possible, also compare the differences of pitch which are 
produced by different lengths of the neck of the bottle, other condi- 
tions remaining the same. Percuss a rubber gas-bag which is at first 
only moderately inflated, then more tensely, with air. In this way one 
can very easily illustrate the most important of the laws that have been 
mentioned. 

3. Finally, tympanitic sound occurs under quite other conditions — 
namely, in certain conditions of the lungs which have this in common, 
that they probably accompany a want of tension of the lung-tissue. 

Referring to what was said above under i, we add that the open 
tympanitic sound occurs in the human body, under normal relations, 
when the month, larynx, and trachea are percussed ; pathologically, 
when percussing Inng-cavities which are in open communication with 
the air-passages; further, if, in consequence of shrinking of the apices 
of the lungs, the trachea, or in consequence of shrinking or thickening 
of the lung where it covers a fissure, a primary bronchus would be 
reached by the percussion-stroke, and would, therefore, be itself per- 



98 SPECIAL DIAGNOSIS. 

cussed ; and, finally, the open tympanitic sound sometimes occurs with 
€pen pneumothorax. 

Herewith we notice a peculiarity of this sound which truly stands 
in a certain (although still not altogether clear) relation to the laws 
above enunciated regarding the pitch of the open tympanitic sound : 
the sound is higher with the mouth open, deeper with the mouth 
closed. If this occurs when percussing a lung-cavity (or also in open 
pneumothorax), it is called WintricKs change of sound ; if on percus- 
sion of the trachea or a primary bronchus, then we speak of Williams's 
tracheal tone} 

In addition to what was said above under 2, we remark that in the 
human body the closed tympanitic sound is heard over the stomach 
and bowels ; in rare cases over closed pneumothorax ; and, finally, in 
pneumopericardium. 

Now, while it is difficult to apply the rules regarding the change of 
pitch to the open tympanitic sound, since the cavities of which we 
are speaking are of extremely complicated form and have very dif- 
ferent walls, the influence on the one side of the volume of the cavity, 
and on the other of the tension of a membranous wall, is shown over 
the stomach and intestines. A greater volume, as in the stomach and 
colon in comparison with that of the small intestine, deepens the sound, 
while increased tension heightens it, and even renders it non-tym- 
panitic. 

We add to what was said above under 3 that the normally clear, 
non-tympanitic sound over the lung becojnes tympanitic if the tension 
of the lung-tissue diminishes — i. e. if the lung, following the pull of its 
elasticity, is able to retract. This is true in all cases where the pleural 
cavity is diminished, hence especially in exudative pleuritis. The tym- 
panitic sound is found where the retracted lung lies against the thorax. 
All the other changes of the thoracic and abdominal cavities which 
have been mentioned before^ as working in the same way, occasion 
these phenomena. 

Probably, for the same reason — i. e. in consequence of the relaxa- 
tion of the lung-tissue — a tympanitic sound is heard in croupous pneu- 
monia during the stages of engorgement and of resolution ; in edema 
of the lungs ; and finally in the neighborhood of thickened parts of the 
lungs. In the latter relation the tympanitic sound over the apices of 
the lungs in the beginning of tuberculosis, where lung-tissue containing 
air is situated between groups of small tubercular masses, is of some 
diagnostic importance. 

In these cases we must assume that the lung-tissue has become 
loose and ductile, and has therefore lost its power of stretching. It 
has not yet been established that this explanation is correct. 

Metallic Sound. — We thus designate such a variety of tympanitic 
sound by which a metallic character, produced by a very high over- 
tone, either occurring with the sound itself, a peculiar metallic tone, 
or it is produced afterward, metallic after-sounds. The metallic sound 
exists over not too small, very smooth-walled, regular cavities, both 
open and closed. Hence, we find it sometimes over the normal stom- 
ach, intestines, and sometimes over lung-cavities ^ in pneumothorax, pneu- 

^ See, regarding this, pp. 106, 113. 2 3ge p g^ 



EXAMINATION OF THE RESPIRATORY APPARATUS. 99 

mopericardium. It is best brought out in percussion with the so-called 
rod pleximeter or in percussion-auscultation (Heubner)/ 

The clear ?ion-tympanitic sound occurs where, " within the sphere 
of action of acoustics, there is found tissue containing air, but whose 
capacity for vibration is more diminished than in those cases in which 
the tympanitic sound occurs." ^ It is heard over the normal lungs — a 
remarkable fact, since a lung that has been removed from the body, 
even if it is inflated to a volume corresponding with the condition 
during life, gives a sound that more nearly approaches the tympanitic 
than the non-tympanitic. Why a lung in the thorax loses wholly the 
tympanitic character of its sound is not entirely clear, but we cannot 
help thinking that, in some way or other, the chest-wall is the cause. 

The intensity of this lung-sound is sufficiently explained by the 
rules given above ; its pitch, only approximately recognizable, is chiefly 
influenced by the tension of the lung-tissue. We have mentioned 
above that retracted and relaxed lung-tissue gives a tympanitic sound ; 
if the tension is only slightly diminished, then there is only a very deep 
{and abnormally clear) non-tympanitic soimd. This occurs, also, in 
emphysema of the lungs, but sometimes in exudative pleurisy, and also 
in pneumonia in the air-containing, compressed, infiltrated adjacent sec- 
tions of the lungs. The transition from the non-tympanitic to the tym- 
panitic sound over the lungs may be thus summarized : According to 
the diminution of the normal tension of the healthy lungs, there takes 
place in the thorax a change of the clear non-tympanitic sound to an 
abnormally clear and deep, and in very marked relaxation to a tym- 
panitic, sound. 

To the above corresponds the fact that in very deep respiration, at 
the height of inspiration, at many points of the thorax, the respiratory 
sound is distinctly higher, while in deep expiration it is deeper (" change 
of respiratory sound " — Friedreich). 

Moreover, we hear the lung-sound over the stomach and bowels if 
they are very much inflated with gas, where gas, as well as wall, is 
under marked tension ; finally, when the walls of the cavities of the 
body are made tense by the entrance of air into them. This espe- 
cially happens in most cases of pneumothorax (except that open pneu- 
mothorax frequently gives a tympanitic sound).^ 

The deadened sound. Absolutely deadened or thigh-sound is met 
with " if only structures that are free from air lie within the sphere 
where the percussion-stroke acts acoustically" (Weil). Since this, at 
best — /. e. with the strongest percussion — reaches only to the depth of 
6 to 7 cm., and not so much as this in a lateral direction, therefore in 
case of only strong percussion absolutely deadened sound, after all, 
would be found where we percussed over airless structure of sufficient 
size if an organ containing air were not directly in contact with it. 
If we percuss still less strongly, we should, as a matter of course, the 
sooner receive an absolutely deadened sound. 

In the human body we have next to consider the internal organs 
not containing air, called *' parietal " if they lie in contact with the wall 
of the body ; and also the coverings (subcutaneous fat, muscles, bones) 

^ See later. 2 \ygji . Handbook of Topographical Percussion, 2d ed,, p. 35. 

^ See above. 



100 SPECIAL DIAGNOSIS. 

if they are of sufficient magnitude. Thus, frequently, in the region 
where the heart is parietal, and, further, where the liver also is, even 
with strong percussion there is absolutely deadened sound. Not 
infrequently, however, especially over the heart, absolute deadening 
does not exist, since the structures containing air lying under or near 
by may be reached chiefly through transmission by the chest- wall. 



Entirely deadened : 

^^^ Lung 

Clear " "" 




Covering of the body : 



Fig. 28. — Diagrammatic representation of percussion over a thick covering of the body. 
The short arrow indicates weak, the long one strong, percussion. With weak percussion we 
have absolutely deadened resonance ; with strong percussion a clear, although less intense, 
sound (indicated by the hatched triangle). 

though it may be only by its vibration, and may give the clear sound 
belonging to the air-containing structures. 

As regards the skeletal coverings, in abnormally fat persons and in 
edematous diseases, these sometimes attain such proportions that even 
strong percussion yields an absolutely deadened sound ; in normal, 
moderately fat persons it is only the fossa infraspinata that very fre- 
quently gives an absolutely dull sound. 

But, further, parietal tumors, and especially fluid accumulations in 
the pleura and peritoneum (more rarely thickening of the lungs), occa- 
sion absolutely deadened sound in case they, together with the skeletal 
covering, possess sufficient depth and breadth. 

Moreover, over ribs markedly bowed, as over the point of sharpest 
bending-out of the thorax in kyphoscoliosis, absolutely deadened 
sound may take the place of the lung-sound ; also here a peculiar change 
of the lung (aplasia) often plays some part. But under the circum- 
stances mentioned above there may be relative or even absolute dulness 
of sound over perfectly normal lung-tissue. 

Furthermore, it is to be remembered that when the body lies on 
pillows, etc., these tend to diminish sound in parts immediately in con- 
tact with them, because the integument and subjacent tissues, particu- 
larly the ribs, do not vibrate so readily when close against anything, 
and for the same reason they cannot transmit vibrations. Thus there 
is dulness in the sloping lateral parts of the thorax if the patient is 
lying upon his back in bed. This dulness, though insignificant, is yet 
pronounced enough to obliterate fine differences or to lead to error 
where a nicer distinction is required. 

Relatively dull sound occurs where air-containing structures of only 
small size are percussed, or where structures containing air are made to 
vibrate only slightly by percussion, or where these two conditions are 
met with together. Thus, a relatively dull sound is obtained with 
feeble percussion of air-containing structures, while strong percussion 



EXAMIXATION OF THE RESPIRATORY APPARATUS. 1 01 

of the same yields a clear sound : the blow reaches only a small volume 
of the air-containing organ, and it moreover causes in it oscillations of 
only moderate amplitude. Likewise, where the volume of lung-tissue 
is small, as over the apices and just over the lower border of the lungs, 
the sound is relatively dull, and this is true even with strongest percus- 
sion, since there is here only a small portion of air-containing material 
to be acted upon. Finally, every layer of airless tissue which lies over 
an air-containing tissue or space causes a deadening of the percussion- 
sound of the latter — /. c. a relatively deadened sound — if the overlying 
layer is not so thick as to cause an absolutely deadened sound.^ Sub- 
cutaneous fat, muscles, bones, parietal tumors, thickening of lungs, 
layers of fluid, callosities, — all these, as overlying airless masses, 
deaden the sound in proportion to their size. 

A special description is required both of parietal and of deeply- 



Clear : — >«ftk 2Vo difference in 

Relatively dull :. -^ clearness 



^ Lung 

Lung 




Weak percussion. Strong percussion. 

Fig. 29. — Diagrammatic representation of the value of gentle percussion in determining 
parietal condensation in the lungs. 

The length of the arrow indicates the strength of the percussion, the size of the hatched triangle the 
extent of the vibrations in breadth and depth. We notice that weak percussion is better, because it gives a 
deadened sound over the thickening, while over the lung it gives a clear sound. 

seated airless parts which normally contain air, such as occur espe- 
cially in the lungs as acute and cJironic pneiunonic tliickenings^ infarc- 



Qear 



f 



Less difference 

Absolutely dull : ^lilHH ^''^ clearness : 




Lung I ^V lAing 



Strong percussion. Weak percussion. 

Fig. 30. — Diagrammatic representation of the value of strong percussion in determining 
condensation in the lungs lying at some distance from the surface. 

The strength of the percussion-stroke is indicated by the length of the arrows. The hatched triangle 
shows the extent of the oscillations in breadth and depth. 

tion, and tumors. For ascertaining such solidifications, if they are 
parietal, it is necessary not to percuss too strongly ; then we shall 

^ See above. 



I02 SPECIAL DIAGNOSIS. 

plainly make out the place where there is air by the difference in sound 
if the given patch of thickening measures as much as about 5 cm. in 
breadth and 2 cm. in depth (see Fig. 29). Deposits which, on the other 
hand, are located at about 3 to 4 cm. in depth, if they are corre- 
spondingly large, may be detected, but only by very strong percus- 
sion ; then we elicit a relatively deadened sound in the midst of what 
is quite normal, as is shown by Fig. 30. 

Sensation of Resistance. — We introduce here the description of 
this symptom, although it really belongs under Palpation, but in truth 
it is most intimately connected with Percussion. 

With the percussing finger (less distinctly with the hammer) the 
examiner forms an opinion of the degree of resistmtce, or, to express it 
better, concerning the degj^ee of capacity of the parts lying beneath it to 
vibrate. This feeling of resistance is strongest, the power to vibrate 
least conceivable, where it is absolutely deadened, the sound identical 
with the " thigh-sound ; " hence, normally, where we strike upon 
thick muscle, also bones and muscles ; pathologically, it is especially 
distinct over large pleuritic exudations, very thick pleura, solid parietal 
tumors of the chest ; over large solid abdominal swellings ; and in 
extremely rare cases in extensive thickening of lungs, where the bronchi 
are completely stopped (as in the so-called " massive pneumonia'' of the 
French). 

When the percussing hammer is used to ascertain the feeling of re- 
sistance the index finger is placed upon the head of the hammer. 
This has always seemed to me a very poor substitute for finger-per- 
cussion. 

Other authors, as Weil, find a marked feeling of resistance only 
over massive layers of fluid. I have often convinced myself of the 
presence of marked resistance in the cases above mentioned. 

4. Topogftaphical Percussion: Determining the Parietal 
Boundaries of Organs. — Only of a part of the internal organs can 
we determine the boundaries by percussion on the surface of the body. 
The conditions of such determinations are these : 
(a) That the given organ be parietal. 
(B) That it yield a sound differing from its surrounding tissues. 

Hence, we can mark off the boundaries of a parietal organ that gives 
an absolutely deadened sound from one that gives a clear (tympanitic 
or non-tympanitic) sound, as the liver from the lung or stomach, the 
heart from the lung ; of a parietal organ that gives a tympanitic sound 
from one that yields a non-tympanitic sound, as the lung from the 
stomach or the intestine ; of parietal organs with tympanitic sounds of 
different pitch, as the stomach from the intestines ; and also, though 
very seldom, two organs of non-tympanitic sound in case they are of 
very different pitch, as pneumothorax from lung lying against the 
opposite side. 

But we can never recognize the boundaries between two organs 
giving deadened sound (heart and liver), nor between the heart and 
fluid effusion in the pleura.^ 

Method of Determining the Boundary. — Generally we percuss from 
an organ that yields a clear sound toward that which gives a deadened 

^ See below. 



EXAMINATION OF THE RESPIRATORY APPARATUS. IO3 

sound, and upon the line which stands perpendicular to the expected 
boundary-hne. Hence the pleximeter or the pleximeter finger is placed 
parallel to where the expected boundary-Hne lies. We proceed by long 
stages upon this perpendicular (striking it at intervals of about 3 cm.), 
until the sound has so distinctly changed that we are convinced that 
we are over another organ. Then we define the boundaries by placing 
the pleximeter at shorter and shorter intervals until we have defined 
the boundaries as sharply as possible. This is traced by means of a 
blue pencil. After the boundaries have been determined at various 
points and they have been thus marked, then the points are united in a 
line, which is the boundary-line of the particular organ. 

TJie rule most important to observe is to percuss very lightly along the 
border of the organ we are trying to locate. It is easy to see the reason 
for this : I. By strong percussion, as of the liver close to the lower bor- 
der of the lungs, we should at the same time disturb the adjacent lung, 
and so would elicit a noticeable clear sound, and we should then easily 
think that we were still over the lung. In the same way, in determin- 
ing the lower border of the liver, by strong percussion we disturb the 
intestine which here lies under the thin portion of the liver, and so get 
a tympanitic tone. 2. The ear perceives the very shght differences of 
sound which exist upon the border-line (we remember the lower border 
of the lung, how the clear sound yielded by it must have slight in- 
tensity) better if the sound is itself slight. 

For those who are trained the simplest method may be recom- 
mended, that on approaching the boundary between the two organs 
one should successively percuss the more lightly. 

The dermatograph of Johann Faber for marking the boundaries on 
the body can be very strongly recommended. 

In important cases it is advisable to mark upon an outline drawing 
of the body what has been found by percussion. One can use with 
great advantage rubber stamps for these outlines. They enable the 
physician to quickly enter his findings at the appropriate place in each 
individual history. 

After this indispensable explanation of the general rules for percus- 
sion and their practical value, we again take up in succession the 
methods of examination of the respiratory organs, beginning with the 
percussion of the thorax. 

Percussion of the Thorax, especially of the Lungs. 

I. Methods. — It is best first to percuss patients who are out of 

bed in the standing posture, and later, if necessary for the front of the 
chest, lying down. Upon bedridden patients the examination of the 
chest is conducted with the patient in the dorsal position ; for percuss- 
ing the back we have the patient sit up. We must then take care that 
the patient sits in a symmetrical position, but with the least possible 
tension of muscles ; the head is held exactly straight, and especially in 
percussing the supraclavicular depressions it must not be turned ; in 
the dorsal position the arms lie quietly by the side of the thorax. 
Both in sitting and standing the patient bows the back a little, inclines 
the head slightly forward, allows the shoulders to hang, and folds the 



104 SPECIAL DIAGNOSIS. 

forearms across the chest. Every contracting muscle increases the 
thickness of the covering by its swelling and increases the impression 
of dulness ; hence, contraction of the muscles of the thorax must as 
much as possible be prevented. 

In finger-percussion of the front of the chest with the patient in the 
dorsal position we approach the bed if possible so as to stand on the 
left side of the patient. From the other side it is not possible to place 
the finger of the left hand, used as a pleximeter, symmetrically ^ upon 
the two sides in both supraclavicular spaces. 

We proceed in such a way as to compare at every situation the 
percussion-note of points that are symmetrically located. We must 
take particular care to strike exactly upon symmetrical points, other- 
wise the " comparative percussion " has no value. Moreover, since 
we wish to make an exact comparison throughout, we take care also 
not only to percuss at symmetrical points, but to percuss with equal 
strength and somewhat moderately. 

We first percuss the supraclavicular depressions — first on the right, 
then on the left, whereby, in cases where it is of special importance, we 
determine the upper boundaries of the apices of the lungs ; then, in the 
same way, the infraclavicular spaces are percussed. On the two sides 
in finger-percussion we must, if possible, hold the pleximeter hand in 
such way as always to have the wrist toward the middle line of the 
thorax and the pleximeter finger pointing outward. 

Then we percuss the third intercostal space right and left, then 
downward only on the right, and usually only in the intercostal spaces. 
We do not further compare it with the left side, since here lies the 
heart, which is percussed by itself Then follows the determination of 
the right lower border of the lungs according to the rules given above 
regarding the determination of parietal organs. We percuss upward, 
comparing the two sides of the thorax, again in the intercostal spaces. 
When we wish to percuss high in the axillae the arms are to be 
abducted. Then follows the determination of the boundaries of the 
right and left borders of the lungs in the middle axillary hnes. Some- 
times it is valuable also to percuss from the infraclavicular spaces side- 
ward and downward upon a line which is at right angles with the 
course of the ribs. 

In percussing the back we first compare the sound over the apices 
of the lungs, thus completely defining their upper boundaries ; then we 
percuss on the right and the left, comparing corresponding intercostal 
spaces as we proceed downward to the lower borders of the lungs. 
Then we percuss on the sides of the spine below the angles of the 
scapulae, comparing symmetrical points. The boundaries of the lungs 
are best determined in the scapular lines. 

In this way the thorax is generally to be percussed. But the 
presence of pathological conditions that require one to be especially 
careful in the examination of certain parts may give the preference to 
special methods of examination. These have been in part already 
mentioned in the general division. They follow directly from what 
was said there. They will be again mentioned in the description of 
percussion in pathological conditions of the lung. 

^ See below. 



EXAMINATION OF THE RESPIRATORY APPARATUS. I05 

2,, Normal Sound over the I/Ungs, Trachea, and I/arynx. — 
The Normal Boundaries of the lyungs. — It is shown that in per- 
cussion of the lungs in general over the normal lung there is elicited a 
non-tympanitic sound. But this sound as regards its intensity is indi- 
vidually very different in different persons ; also, in each single chest it 
is not alike throughout, but exhibits individual regional differences. 

The individual variations arrange themselves first according to the 
amount of fat. Very fat bodies give a less clear thoracic sound, or in 
order to yield a clear sound they must be percussed more strongly, 
requiring perhaps the use of the hammer ; but it is evident, as we have 
said, that this is unfavorable for determining the boundaries, for which 
the rule is to employ very light percussion.' 

Further, the percussion-note of the chest differs according to age : 
with children, having a more elastic thorax, as well as with aged per- 
sons, with thin structural coverings and somewhat lax or rarefied 
lungs, it is higher in pitch than in persons in middle life. 

But also in the individual thorax the different regions normally 
give different clearness of sound. In other words, one region com- 
pared with another yields a relatively deadened sound, and according 
to the two chief points of view previously mentioned — namely, accord- 
ing to the varying thickness of the covering and according to the size 
of the lungs. Hence we remark the following facts : 

(a) Over the apices of the lungs, even with strong percussion, the 
sound is not very intense ; for, though the covering is thin, the volume 
of lung-tissue is small. 

{6) In the infraclavicular spaces, and still more in the second inter- 
costal spaces, the sound is very intense (covering thin; volume of lung- 
tissue greater). 

(c) Farther down, not only in the male, but in still higher degree in 
the female, the sound is deadened by the pectoral muscle or by this 
and the mamma ; in the female the sound may be absolutely deadened 
over the mamma, and this notwithstanding the fact that the lung-tissue 
is here very considerable. 

id) upon the back the apices yield a sound of very slight intensity, 
since here there is a very small volume of lung and a very thick body 
of muscle Over the scapidce there is likewise a very deadened sound — 
at the spine and directly below even a thigh-sound. In the interscap- 
ular spaces the sound is clearer. 

if) Beloiv the scapulce and at the sides of the chest the sound is very 
intense. 

(/) Strictly speaking, here also belongs the description of the so- 
called ''relative heart- and liver-dulness.'''^ 

Now, it is further very important to know which similarly situated 
points on the thorax normally give the same kind of sound, since it is 
especially by comparative percussion that we seek to ascertain the 
presence of disease on one side. We may say that in healthy people 
marked dissimilarity of sound at symmetrical parts of the chest on the 
right and left sides exists only — 

In the neighborhood of the heart, as compared with the correspond- 
ing part on the right. 

^ See above. 2 ggg p jog. 



I06 SPECIAL DIAGNOSIS. 

At the two sides : on the left side normally the sound, almost as far 
back as the spine and forward in front at varying height as far some- 
times as the fourth rib, is often clearer than on the right, and of some- 
what tympanitic tone (combining with the sound of the stomach or 
colon). 

In addition, there is a slight inequality sometimes posteriorly over 
the apices. In right-handed persons the sound on the right side at 
that location may sometimes be met with a little less clear, because 
the muscles from use are somewhat more developed. On the left side, 
in left-handed persons, the case is reversed. 

Lastly, it is necessary to mention a point of greater importance — that 
over the whole of the sternum there is a clearer, non-tympanitic sound 
even where there is no lung-tissue at all, as at the upper part of the 
manubrium (trachea) and over the left half of the lower part of the 
corpus sterni. The sternum acts as an unusually thick pleximeter, and 
yields, therefore, throughout and in equal strength, the sound of the 
lung lying in contact spread out over its inner surface. 

The larynx and trachea in the neck in front give the tympanitic 
sound of a hollow cavity with smooth walls. This has the peculiarity 
of being higher and more plainly tympanitic with the mouth open than 
with it closed (Williams's tracheal tone, tracheal change of sound). 
The cause of this phenomenon is not quite clear; the explanation 
given by Neukirch and accepted by Weil is based upon the assumption 
of the resonance of the mouth changing with its opening and closing. 
This will be referred to later. 

Normal Percussion-boundaries of the Lungs. ^— It is not possible 
to define the boundaries of the lungs perfectly by percussion. More- 
over, by percussion we can only establish — 

1 . The apices so far as they rise above the clavicle : they are dis- 
tinguished by their clear sound in comparison with the deadened 
sound of their surrounding soft parts. 

2. The boundaries of the left lung at the incisura cardiaca : the 
lung sound from the absolutely deadened sound of the heart — the 
lung-heart boundary. 

3. The lower borders of the lungs, this especially at the lower border 
of the right lung : the lung sound marks the boundary of the abso- 
lutely deadened sound of the liver — the lung-liver boundary. 

At the lower border of the left lung, first about from the mam- 
millary to the middle of the middle axillary line, the lung sound marks 
the boundary of the tympanitic sound (stomach, or more rarely also 
intestines) — lung-stomach boundary ; next, the lung sound from the 
deadened sound of the spleen — lung-spleeit boundary ; and, lastly, from 
the deadened sound of the kidney — the lung-kidney boundary. 

It is difficult to determine the boundaries of the lungs, since the 
difference of sound is often slight, especially as the tympanitic sound 
of the stomach often mingles with the lung-sound higher up than the 
anatomical border of the lower limits of the lungs ; moreover, the 
lower boundaries of the lungs close up to the spine on both sides, 
because of the thick layers of the erector spinae, require strong per- 
cussion, and this is unfavorable for determining the boundaries.^ 

^ Compare Figs. 31 and 32. ^ See above. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 



107 




Fig. 31. — Boundary of the lungs as determined by percussion in front (after Weil). 

g, h, the extent of the lung upward ; e,/, the lower limit of the lungs ; b, d, the relations of the lung and 
heart at the incisura cardiaca. The strongly-hatched surface represents the portions of the heart and liver 
which are parietal; the lighter hatching shows the so-called relative heart- and liver-deadness.i 




Fig. 



32. — Boundary of the lungs as determined by percussion upon the back (after Weil), 
a, b, the upper limits of the lungs ; c, d, lower limits. 

^ See below. 



I08 SPECIAL DIAGNOSIS. 

We cannot determine by percussion the front borders of the lungs 
behind the sternum. This is the case because there the lungs lie close 
to each other for some distance, and also because the sternum, like 
a firm bone, yields a uniform sound, and it is not possible to recognize 
a difference of sound in what lies beneath it : it yields throughout a 
clear sound, very like the lung resonance over the ribs. 

Hence, it may also be explained that the lower part of the anterior 
border of the right lung, which behind the sternum is Hmited by the 
heart, cannot be defined by percussion : we much more receive, instead 
of the actual boundary of the right lung, one that is apparent — where 
the uniform sternal sound is exchanged for the absolutely deadened 
sound of the heart at the left border of the sternum. In front the base 
of the right lung does not extend so far down as the left, the right 
coming as low as the inferior border of the fifth rib, while the left cor- 
responds with the superior border of the sixth rib. 

Relative Jicart- and liver-dulness. The determination of the lung- 
heart and the lung-liver boundaries is made more difficult by the 
peculiar circumstance that, on account of the small volume of lung- 
tissue at the border of the lungs, the resonance of the lungs imme- 
diately over the borders has very slight intensity, a relatively deadened 
sound. We percuss from the lung toward the liver with strong or 
moderately strong strokes, and find, say in the mammillary line at the 
fifth rib, a strong relatively deadened sound which the beginner is 
inclined to regard as absolute liver-dulness. But this, as has been said, 
corresponds with the thinning of the lungs at the lower border. In 
this way a zone of relative dulness manifests itself over the whole of 
the lower border of the right lung, except close to the spine behind, 
and in a similar, but somewhat smaller, zone the heart-dulness bows 
round and to the left : this is the (incorrectly) so-called relative liver- 
and relative heart-dulness, as indicated by the light shading in Figs. 31 
and 32. Also, sometimes, there is such a relative dulness over the 
lung-spleen boundary. It does not exist over the lung-stomach 
boundary, because here, by moderate percussion, the coincident sound 
of the stomach causes a low tympanitic sound. 

These zones are diagnostically important only in isolated cases, 
and they have nothing to do with enlargement of the heart, liver, or 
spleen. 

In order to avoid deception by these conditions Avhen determining 
the boundaries it is necessary to take care — 

1. To percuss lightly in determining the boundaries of the lungs. 

2. To mark the lung-heart and the lung-liver boundary — that is, the 
border of the lungs where the relative dulness passes into absolute 
dulness, or, in other words, where, in percussing from the lungs toward 
the heart and the liver, the dulness begins to be so marked that it no 
longer increases. 

On the average — that is, in middle life — we thus find (compare Figs. 
31 and 32) the lung-liver boundary, in the mammillary line at the sixth, 
in the middle axillary line at the eighth, in the scapulary line at the 
tenth rib ; the lower border of the left lung, in general as high as the 
right only in the mammillary line at the lower border of the sixth rib ; 
the lung-heart boundary, at the fourth rib and more or less just without 



EXAMINATION OF THE RESPIRATORY APPARATUS. IO9 

the parasternal line ; tJie upper limits of the apices of the lungs, three to 
five cm. above the clavicle. 

Differences by reason of age. In children the lower border of the 
lungs is from a half to a whole intercostal space higher ; in old persons 
it is that much lower (Weil). There is a like difference as regards the 
lung-heart boundary. That is, the lungs increase with the years as 
compared with other organs. 

Displacement of lower border of the lungs is manifest by percussion : 

1 . In deep inspiration and expiration (active mobility) : in the mid- 
dle axillary line the lower border sinks with deepest inspiration about 
three to four cm. ; in the mammillary and scapular lines, about two to 
three cm. ; in deepest expiration it rises up not quite so much above 
the average location (Weil). With deep inspiration at the incisura 
cardiaca the lung moves so as quite to cover the heart, and it may even 
entirely obscure the heart-dulness. 

2. In change of position (passive mobility) : when lying upon one 
or the other side the lower border of the lung of the opposite side 
moves down as much as three to four cm. (Gerhardt, Salter, Weil). 

3. Abnormal Sound over the I/Ungs. Abnormal Position 
of the Border of the I/Ungs.— A. Dulness : Deadened Resonance. 
— In order not to overlook slight deadening we must remember what 
was said upon comparative percussion on pages 104, 105 ; if the com- 
parison with the opposite side is inadmissible, as when both sides are 
diseased, then the comparison is made with the adjacent parts upon the 
same side, bearing in mind the normal regional differences of intensity 
of sound.^ 

Thus, in disease of both apices we sometimes recognize the dead- 
ness of the apex to be less affected by comparing the resonance over 
the latter with the percussion-resonance a little lower down, remem- 
bering that normally the resonance over the first and second inter- 
costal spaces must be clearer than in the supraclavicular space, and 
clearer than over the third intercostal space. 

But also, without further consideration, we must not designate every 
deadness as due to an internal organ, but consider the deadening 
influence of a sharply-bowed rib, etc. Slight deadening, without any 
other pathological evidence, especially over the apices, is to be given 
value with very great caution. 

Resonance is deadened : 

{a) By the development of airless tissue in the lungs, either by con- 
densation or by solid new formations in them. 

In croupous pneumonia the lung-tissue in the height of the disease is 
in the stage of hepatization. Generally, in a large region it is com- 
pletely deprived of air through the fiUing of the alveoH with inflamma- 
tory exudate. An intense deadening is coextensive with this condi- 
tion. It seldom becomes absolutely deadened Hke the thigh-sound, 
but there can generally be recognized a sHght tympanitic tone. The 
feeling of resistajtce is generally likewise correspondingly increased, 
but not so much as is the case with a pleuritic exudate. 

Thigh-dulness and very marked feeling of resistance may exist with 
croupous pneumonia if, besides the lung-tissue, the bronchial tubes of 

^ See above. 



no SPECIAL DIAGNOSIS. 

that part of the lung are Hkewise completely filled with the exudate 
C' massive pneumonia "), or if the croupous pneumonia is compHcated 
with a large pleuritic exudate, which is then almost always behind 
and low in the chest. The extent of the deadening in croupous pneu- 
monia very frequently corresponds with a lobe of the lung, because of 
its being a lobar pneumonia, or there is evidence of an enlargement of 
the lobe in all directions (the inflammatory exudate spreads out to a 
considerable extent). Often, therefore, in this disease we may recog- 
nize the boundaries of the lobe in the figure of the area of deadening, 
or the boundaries which correspond to the tracing of the lobe enlarged 
in all directions. The infiltrated part of the lung may, however, be 
also smaller, especially on the surface of the lungs, occupying so small 
an extent as not to cause any recognizable deadening. Auscultation ^ 
here leads to a conclusion sooner than percussion. 

In the neighborhood of an infiltration the resonance is generally 
abnormally loud and deep, even slightly tympanitic (compare what is 
said of croupous pneumonia under B. Tympanitic Sound).^ 

Since the infiltrated lobe of the lung is somewhat larger than 
normal, sometimes in pneumonia of the whole lower lobe deadness 
will be found posteriorly as far up as the apex without the apex being 
involved. On the contrary, percussion upon the front of the chest, 
over the apices of the lungs, then yields a clear and, in consequence of 
the relaxation, a very loud, deep sound. Further, for the same reason, 
in pneumonia of the left lower lobe the lower border of the deadness 
may overstep the region of the normal boundaries of the lungs, as the 
marking out of the lung-stomach boundary then shows that the 
so-called " halfmoon-shaped space " is somewhat smaller.^ 

Also in catarrJial or lobular pneumonia and tuberculosis (in the 
so-called infiltrated tuberculosis of a larger part of the lungs) there 
may be an extended thickening and a corresponding deadening. 
Often, indeed, there are pathological deposits so small that their 
presence is not revealed by percussion, but, though widely scattered, 
they are interspersed with points still containing air, and hence give a 
clear sound. Then, because the tissue of the parts still remaining 
normal is somewhat lax, the resonance is often tympanitic, or the latter 
sound is mingled with that of deadness from the infiltrated parts — the 
tympanitic deadened sound. 

In tuberculosis of the apices of the lungs there is, at the beginning, 
in very slight measure, a mingling of thickened parts with tissue con- 
taining air, but relaxed ; hence the resonance in the beginning over the 
diseased apex is very often tympanitic or tympanitic-deadened, in com- 
parison with the healthy apex. Moreover, there is early retraction of 
the upper boundary of the apex upon the affected side.* 

Large hemorrhagic infarctions and sections of the lungs compressed 
even to the point of not containing any air, as from pleuritic exuda- 
tions, tumors, and large pericardial exudations, may likewise give a 
deadened sound. Finally, it is conceivable that soHd tumors of the 
lungs (sarcoma, carcinoma) produce the same effects if they He upon 
the surface or attain to a certain size. 

1 See Auscultation. ^ P. 112. ^ See under Digestive Apparatus. 

* See under Diminution of the Boundaries of the Lungs. 



EXAMINATION OF THE RESPIRATORY APPARATUS. Ill 

{b^ Resonance is deadened by the presence of a deadening medinm 
over the lungs — that is, between it and the percussing finger. 

Most important of these is pleuritic exudate. Generally, this first 
appears low down posteriorly in the complementary space and above 
it, and if it amounts to as much as 400 cubic cm., it may even be 
recognized by light percussion. Corresponding with the increase 
of the exudate the area of deadness will gradually become more 
extensive ; its limits ordinarily correspond with a fluid surface which, 
while the patient is in the posture most frequently assumed, is some- 
what horizontal ; that is to say, in bedridden patients the fluid levels 
itself high up on the posterior wall of the thorax, and the limits on the 
sides and in front drop off sharply, while with people who are much 
-out of bed or may still be at work the fluid stands equally high in 
front and at the back of the chest. When the effusion is very large 
the deadness may extend even to the apex, both anteriorly and pos- 
teriorly. When the effusion is considerable, it quickly causes an abso- 
lute deadening and with the most marked feeling of resistance. 

Corresponding with the increase of the fluid the lung becomes lax 
in an ever-increasing area, since it may then follow its elastic traction ; 
immediately over the fluid it gives deadness, and when there is a large 
exudate, where at least there is ordinarily left a district with clear 
sound — namely, high in front — it yields an abnormally loud and deep, 
or a tympanitic sound, sometimes cracked-pot sound} A very large 
exudate may even compress the lung to such a degree as to expel 
all air.^ 

When there is a certain amount of exudation its weight presses 
upon the diaphragm, increases the affected pleural cavity toward the 
side, presses out the side of the thorax,^ and pushes the mediastinum 
and the heart over toward the sound side.* The downward pressure 
of the diaphragm in cases of pleurisy of the right side is recognized by 
the liver being lower.^ In pleurisy of the left side it may be made 
out directly by locating the upper boundary of the so-called '' half- 
inoon-shaped space." 

When the pleural surfaces directly over the exudate are glued 
together, then in change of position of the patient the pleuritic exudate 
is not movable, and the boundaries of the deadness are therefore not 
■changeable ; not infrequently the exudate is entirely ** capsulated" by 
the adhesion of the pleural surfaces. If the exudate is reabsorbed, 
then the evidences of expansion and of displacement, on the one hand, 
and the deadness (and, indeed, according to its extent, likewise its 
intensity), on the other hand, steadily disappear. Often the upper 
border of deadness then shows as a bowed line with its convexity 
upward (Damoiseau' s curve). 

If a new pleuritic exudation takes place between pleural surfaces 
already adherent from a former attack, then, of course, it remains con- 
fined within the space thus prepared — "encapsulated, circumscribed 
pleurisy." The boundaries of the exudate may, in these cases, take 
a very varying course. 

Hydrothorax practically gives rise to similar appearances, but it is 

^ See page ii6. 2 5gg above. ^ See above. 

* See Displacement of the Heart. 5 See Percussion of the Liver. 



112 SPECIAL DIAGNOSIS, 

generally on both sides, yet not infrequently with a very different 
amount upon the two sides. Further, hydrothorax always shows in 
change of position, although only after a certain time, a change of its 
relation to the thorax in such a way that it tends to take possession of 
the part of the thorax that, for the time being, is the lowest ; accord- 
ingly, there is what may be called a passive mobility of the boundaries 
of deadness. 

Serous oi' purulent or ichorous effusion into the pleural cavity com- 
pHcating pneumothorax (sero-, pyopneumothorax) is distinguished 
from the above by its mobility with the change of posture. It behaves 
like water in a bottle when the position of the latter is changed ; in 
every situation the fluid maintains a horizontal surface, and occasions 
at the same time, with every change of place or location of the thorax, 
a prompt variation of the upper boundaries of the deadness. 

Further, a deadening of the resonance is occasioned by the thick- 
ening of the pleura, which either remains after an exudative pleuritis or 
in conjunction with processes slowly going on in the lungs. The latter 
is very frequently the case in tuberculosis of the apices of the lungs : 
marked deadening, appearing early in the beginning of the disease, is 
generally caused by pleural thickening. The intensity of the deadness 
is determined by the amount of the thickening ; it may even become 
like thigh-deadness. The feeling of resistance is generally very mark- 
edly increased ; with very thick deposit this is positive. Tumors, as 
a matter of course, likewise cause deadening. This latter deadening 
generally exhibits an irregular boundary, unless, as is rarely the case, 
complicated by pleuritic exudations. 

It is sometimes very difficult to distinguish between a thickened 
pleural surface and a portion of pleural exudate left behind with 
moderate thickening; this question often arises especially where the 
deadness is low down posteriorly. In arriving at a decision the first 
thing to consider is whether there is expansion or contraction, or 
whether there is a deep or a high position, of the diaphragm. 

But here, as well as in the often very difficult differential diagnosis 
between pleural exudations and tumors, as of the lungs, pleura, or 
chest-wall, the application of the explorative puncture is the best 
means of deciding. 

Finally, the resonance of the thorax is deadened by all processes 
in the chest-wall which lead to its being thickened — tumors, peri- 
pleuritis, edema. 

The second quality of sound which is found over diseased lungs is — 

B. Tympanitic Sound. — It occurs pathologically : {a) if the lung 
is in a state of elastic equilibrium. We know that this condition is a 
consequence of retraction of the lung, with large pleuritic exudation as 
well as shrinking in connection with pleurisy ; further, in all other 
affections of the chest which decrease its capacity. Hence tympanitic 
resonance exists over the lungs in the neighborhood of tumors of all 
kinds ; sometimes in the neighborhood of the heart in exudative peri- 
carditis, more rarely in hypertrophy and dilatation of the heart ; lower 
in the thorax : in diaphragmatic pleurisy ; in high position of the 
diaphragm from subphrenic tumors, abscesses, etc.; and in general peri- 
tonitis from general distention of the abdomen by ascites, tumors, etc. 



EXAMINATION OF THE RESPIRATORY APPARATUS. II3 

We may also think of the same condition of approaching equilibrium 
of elasticity as arising from relaxation of the lung-tissue (Weil) ; and 
this will explain the tympanitic resonance that exists with croupous 
pneumonia in the stage of engorgement and resolution ; over many 
small catarrhal-pnewnonic and tubercular deposits, since the interven- 
ing tissue containing air has become lax ; and, finally, in edema of the 
limgs. 

\b) In consequence of marked shrinking and tJiickening of the lung, 
in strong percussion of the supraclavicular fossa, it arises from the 
trachea, while in percussing the first or second intercostal space it 
arises from this or the primary bronchus, directly from the percussion- 
blow, and so the broncho-tracheal column of air is put in vibration ; 
there is thus produced a peculiar change of sound in the trachea, the 
sound with the mouth open being more distinctly tympanitic and higher 
( Williams's tracJieal sowtd). 

(c) Over cavities within the lungs, caverns (vomicce). 

We may have here, according as the cavity does or does not com- 
municate with the outer air by means of a pervious bronchial tube, the 
open or the closed tympanitic resonance. In the former case the sound 
under all circumstances is more distinctly tympanitic, and also more 
intense ; in the latter case, on the other hand, it is much less distinct and 
weaker, all the more since we must assume that the cavities, because 
they lie in the thorax, have more or less stiff walls, and since the 
rigidity of the wall with the cavity closed hinders the condition that 
causes the tympanitic sound.^ 

How large the cavity must be in order to give a tympanitic sound 
it is not possible exactly to state, since, besides the size, the situation 
of the cavity (whether parietal or deep), the amount of fluid secretion 
it contains, its walls (whether smooth and vibratory), the condition of 
the surrounding lung-tissue, and finally the vibratory capacity of the 
given thorax, must also be taken into consideration. Generally, cavi- 
ties occurring in the apices from tuberculosis exhibit more distinct 
physical characteristics than cavities in the lower portions of the lungs, 
which frequently are of the nature of bronchiectasis, since the former, 
even when of moderate size, must reach to the surface of the lungs, 
and generally have thickened walls. Cavities as large as a walnut in 
the upper parts of the lungs generally give a distinctly tympanitic 
resonance. 

If the cavity is very large with relatively smooth walls, a metallic 
tone is added to the tympanitic resonance. 

If the cavity is covered by thickened lung-tissue or with thickened 
pleura, as is frequently the case, then the sound becomes tympanitic- 
deadened ; if covered by a very thick layer of airless tissue, possibly 
absolutely deadened. 

Temporarily marked filling of the cavity with secretion deadens the 
tympanitic sound also, sometimes even to absolute deadening; further, 
the sound becomes temporarily indistinctly tympanitic and deadened- 
tympanitic if a bronchus connecting with it, otherwise open, becomes 
closed (with secretion or from dipping below the fluid contents of the 
cavity). 

1 See p. 97. 



I 14 SPECIAL DIAGNOSIS. 

Under different conditions a tympanitic sound over a cavity may 
change its pitch: 

1. The so-called simple Wintrich's Change of Sound. The tym- 
panitic sound becomes louder, more distinctly tympanitic, and higher 
if the patient opens the mouth wide and, as is desirable, at the same 
time protrudes the tongue a little. This can only occur over those 
cavities that freely communicate with the broncho-tracheal column 
of air. 

We percuss, not too strongly, while the patient lies or stands quietly 
and alternately opens and closes the mouth ; but it is necessary for the 
patient to breathe as superficially as possible, or we must compare the 
sound in the same stage of the breathing, since the sound also some- 
times changes its pitch according to the stage of the breath.^ 

The explanation of this symptom, as of the tracheal change of 
sound, which is exactly similar, is that it is from the change of con- 
sonance of the mouth-throat cavity. [See preceding page. — Tr.] 

This Wintrichs change of sound may also occur over cavities in 
such a way that the sound with the mouth closed is markedly dead- 
ened, with only a trace of tympanitic sound (especially with marked 
callous formations over the cavity), and only with the mouth open 
does the sound become tympanitic (at the same time becoming louder 
and noticeably higher). 

I would like, therefore, in opposition to Weil, to insist that we 
ought, if there is only a slight possibility of the existence of a cavity, 
and also in the case of tympanitic sound shghtly distinct, or indis- 
tinct, with dulness, to apply the test of Wintrich's change of sound. 

It is very easy to confound the siinple Wintricks change of sound 
with Williams' s tracheal sound. We should take notice — (i) Whether 
there is very marked contraction, when it is much more likely to indi- 
cate change of sound than Williams's tracheal sound ; (2) Whether in 
order to cause the change of sound only weak percussion (cavity) or 
strong percussion (trachea or bronchus) is required ; (3) Whether 
there are other symptoms of a cavity. 

Simple Wintrich's change of sound points with greater probability 
to a cavity. But its value as an indication is diminished by the above- 
mentioned possibility of being confounded with Williams's tracheal 
sound. 

2. Interrupted Wintrich's CJiange of Sound (Gerhardt, Moritz). It 
is distinguished from the simple in that in some positions of the body 
it is plain, in others it is indistinct or is wanting. The explanation of 
this is that in one position the bronchus leading to the cavity is open, 
while in the other it dips into the secretion in the cavity, and so is 
closed. In this way the tracheal change of sound cannot possibly be 
interrupted. 

This change of sound is very rarely met with, but it is to be 
regarded as a positive sign of a cavity. 

Rumpf ^ recently found in four patients Wintrich's change of sound, 
which only was manifest if the acme of sound was always compared 
with the acme of inspiration ; which change, however, was always 

^ Compare under 4, Respiratory Change of Sound, p. 115. 
"^ Bei'liner klht. Wochenschrift, 1890. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 



115 



absent during other phases of respiration. At the autopsy of all four 
cases cavities were found. Rumpf quite plausibly draws the deduction 
from obvious physical reasons (which we cannot here follow) that such 
a change of sound must necessarily accompany a pathological cavity. 
Parenthetically, we remark that, according to Rumpf's description, it 
seems to us that what he observed is analogous to Seitz's metamor- 
phosing breathing.^ We must wait for further observations. 

The designation " respiratory change of acme of sound " we consider 
to be questionable, for the reason that it may cause confusion with 
Friedreich's respiratory change of sound.^ 

3. Gerhardfs Change of Sound. — A tympanitic sound changes its 
pitch if the patient changes his posture (upright, 
dorsal, side position); and sometimes, if the pa- 
tient changes from the dorsal to the upright 
position, the sound becomes deadened-tympa- 
nitic or absolutely deadened over the lower part 





Fig. 34. 

Figs. 33, 34. — Gerhardt's change of sound. Schematic representation of the behavior of the 
contents of a cavity with a change of position of the body of the patient. 

of the cavity, because in this position the fluid contents of the cavity 
come into contact with the chest-wall. 

Gerhardt's change of sound may take place over communicating, as 
well as over closed, cavities. The change of pitch, in case the cavity is 
open, may have very different causes, which we will not discuss here. 
In closed cavities it is really due to a change in the tension of the chest 
(and cavity ?) wall, perhaps also to a change in the size of the part of 
the cavity containing air — a change caused by different location of the 
secretion. (See Figs. 33 and 34, from WeiVs Handbook) 

Gerhardt's change of sound is in every form an almost certain 
symptom of a cavity, but, like the preceding, it is very rare. 

4. Friedreich's Respiratojy Change of Sonnd : the sound becomes 
higher at the height of a deep inspiration. This occurs not alone over 
cavities, but may be observed in any case of tympanitic sound over the 
lungs. It depends upon the increased tension during inspiration of the 
chest-wall and lung-tissues, likewise of the wall of the cavity. 

It does not have diagnostic significance. But it is important to 
know it in order that we may not be misled by it in the examination 
of other changes of sound ; therefore, we ought in testing this to 
observe the rule to percuss during very superficial breathing, or, still 
better, always to percuss at the same stage of the breathing, as has 
been said above. 



^ See p. 127. 



2 See belovi^. 



Il6 SPECIAL DIAGNOSIS. 

{d) Finally, the tympanitic sound occurs in very rare cases in 
pneumothorax, and sometimes entirely in cases that have permanent 
and completely-open fistulae ; this " open " pneumothorax is generally 
circumscribed. In pneumothorax the tympanitic sound may some- 
times exhibit Wintrich's change, since the physical conditions upon 
which it depends are also present, as in large communicating cavities : 
open communication of an air-space with the broncho-tracheal column 
of air. Here we have also metallic tone (see p. 1 13). 

Cracked-pot Sound {Bruit de pot file)} — It seems that this is the 
most suitable place to describe this phenomenon, which, while very 
surprising and remarkable, is of very subordinate diagnostic signif- 
icance. It consists of a peculiar click (" clinking of coin " or " trem- 
bling ") which sometimes accompanies the clear sound, and indeed 
generally the tympanitic, more rarely the clear, non-tympanitic. It 
corresponds to the noise which occurs when we strike a cracked plate 
or pot, or when we hold the palms of the hands together lightly and 
then strike them upon the knee. It occurs in the thorax if an instan- 
taneous current of air of a given force is driven by the percussion-stroke 
from the lungs against the larynx, or if during expiration a stream of 
air flowing outward is for a moment suddenly sharply arrested. This 
symptom requires strong percussion, yielding thorax, and thin cov- 
ering (generally in front superiorly and also below posteriorly). It 
sometimes occurs in normal cases, almost only in children. 

Pathologically it occurs — 

1 . Over lai^ge parietal cavities, here often remarkably intense. 

2. \x\ pneumothorax with open fistula, especially if circumscribed. 

3. Over pneumonic deposits. 

4. Over retracted lung-tissue, especially above large pleuritic exu- 
dates (high in front), rarely in the neighborhood of thickened portions 
of lung. 

This phenomenon is always more distinct if we percuss during 
expiration ; very often, especially in case of cavity and open pneumo- 
thorax, it becomes louder by opening the mouth. 

As above remarked, this symptom has almost no diagnostic mean- 
ing, since it is present with such varying conditions. 

The noise is caused by a swift current of air striking at a narrowed 
point : this happens at the glottis, in a cavity at the mouth of a 
bronchus, and at the puncture in the pleura in case of pneumothorax. 
Sometimes a rattling sound is mingled with the trembling (" the moist 
cracked-pot sound "). 

C. Abnormally Loud and Deep Sound. — This occurs — 

1. In severe emphysema of the lungs, designated as ** band-box note " 
{Biermcr). 

2. In decreased tension of lung-tissue above a pleuritic exudate. A 
zone of this abnormal sound lies just above the line of deadness pro- 
duced by an exudation in the neighborhood of pneumonic thickening 
— as anteriorly in pneumonia of a whole lower lobe ; sometimes in the 
neighborhood of the heart in pericarditis exudativa, but also with dila- 
tation and hypertrophy ; likewise and especially, in the neighborhood 

^ Referred to on p. in. 



EXAMINA TION OF THE RESPIRA TOR V A P PARA TUS. 1 1 / 

of encroaching tumors, and with a high position of the diaphragm 
consequent upon abdominal affections. 

As was said before, in most of these cases, if the tension of the 
lung-tissue is very considerable tympanitic resonance may arise.^ 

3. With Pneumothorax. — Here the sound, in consequence of the 
strong tension of the chest-wall, is almost always non-tympanitic, loud, 
and deep. Only (a rare case) in open pneumothorax, especially if it be 
circumscribed, is tympanitic sound sometimes met with.^ 

This abnormally loud and deep, even tympanitic sound of pneumo- 
thorax gives almost regularly the metallic soundf only seldom recog- 
nizable, however, by the ordinary methods of percussion, but very 
admirably by the rod-pleximeter percussion described by Heubner. 

Mode of Application. — Rod-pleximeter percussion is best conducted 
by two examiners. One strikes with the handle of the percussion- 
hammer or with a pencil upon a pleximeter; the other auscults the 
thorax. If both manipulate over a pneumothoracic cavity, the second 
hears the strokes as the finest metallic, generally a silvery, clear 
ringing. 

This, moreover, is sometimes also observed with very large and 
smooth-walled cavities with thin covering. With pneumothorax accom- 
panied with fluid (pyo-, seropneumothorax) the metallic sound, almost 
without exception, changes its pitch with the change of position; in 
sitting up it is generally deeper, but sometimes also higher {Biermers 
change of soundf. If the effusion is so large as entirely, or almost 
entirely, to fill the pleural cavity, of course the metallic sound dis- 
appears. 

It will be mentioned in the appropriate sections that this metaUic 
ringing in pneumothorax not only accompanies such an artificially 
created sound, but also may be present with rhonchus, respiratory 
sound, and heart-sound. 

D. Changed Condition (and Diminished Power of Displacement) 
of the Boundaries of the Lungs. — {d) Extension of the boimdaries of 
the lungs takes place in emphysema : the lower borders usually move 
sidewise and deeper, in the most marked cases, both front and back. 
The mammillary line will be at the eighth rib, the axillary line at the 
tenth, the scapular line at the eleventh or twelfth. Heart-deadness 
may almost or quite disappear from the expanded lung lying over it from 
the side. At the apices of the lungs sometimes a slight enlargement 
of the lungs may be made out ; in rare cases even expansion of the 
apices may likewise take place (as after whooping-cough in children). 
" Relative liver- " and '* heart-dulness " is very small ; simultaneously 
with the expansion the lung loses its power of displacement, both 
active and passive, even past recognition. 

One-sided downward movement of the boundary of the lung occurs 
in vicarious emphysema, but the capacity to change its boundaries is 
preserved in this case. 

Apparent one-sided expansion of the boundary — that is to say, the 

appearance of a clear sound upon one side qidte beyond the normal 

boundary of the lung — takes place in diffuse pneumothorax : the lower 

border of the clear sound is sometimes met with even deeper than in 

^ See p. 112. ''Seep. 116. 3 See pp. 113, 116. 



Il8 SPECIAL DIAGNOSIS. 

emphysema. This border is immovable, and always very sharply de- 
fined. The side of the thorax is expanded, the heart and also the liver 
are displaced, or the tympanitic sound of the " halfmoon-shaped " ^ 
space is replaced by the sound of pneumothorax. Displacement of 
the mediastinum in right-sided pneumothorax is generally distinctly 
recognized by the change of sound between it and the left lung (the 
boundary-line lies to the left of the upper part of the sternum). 

{B) Diininislied volume of the lungs is shown by the lower bound- 
aries of the lungs being higher than normal on both sides, by the 
diaphragm being pressed up from below, or from its being paralyzed ; 
one-sided diminution, by shrinking from disease of the lung or a past 
pleurisy. The motility of the borders is thus diminished or destroyed. 
The liver stands correspondingly higher^ or the "halfmoon-shaped" 
space is enlarged. 

Sometimes in phthisis diminution in size of an apex manifests itself 
by the deeper position of the upper border of the lung upon one side. 

(c) Diminution of the motility alone, especially during respiration, 
without change of the average condition of the borders, sometimes 
exists low down posteriorly as the fi7'st symptom of pleurisy, and also 
as the only sign of a past pleurisy, in which case it is noticed along the 
whole lower border of a lung or a part of the same, as at the heart ; 
here, also, it is a residuum of pericarditis externa.^ 

Retraction of the lungs in the neighborhood of the heart by shrinking 
permits the latter to come in contact with the chest-wall to a larger 
extent than normal ; there is displacement of the heart-border of the 
lung to the left and upward, and hence hypertrophy or dilatation of 
the heart may at first be mistaken for the real condition.* 

On the other hand, diseased conditions in the neck (tumors, scars, 
etc.) may influence the position of the apices, and thus at first may 
deceive the inexperienced examiner in leading him to conclude that 
there is one-sided shrinking of the lung. 

Auscultation of the Lungs. 

I. History. — The Sphere of Auscultation at the Present 
Time. — It now appears to us very strange that the idea of percussing 
the body was only so lately brought into medical practice. It is yet 
more difficult to understand that methodical auscidtation of the body is 
only a child of the most recent time. It is true that Hippocrates heard 
what he named a succussion-sound, and also, no doubt, rattling and 
rubbing sounds, but to the latter two he did not attach any great 
importance ; and in all the centuries from the Greek physician to the 
time of Laennec no real attention was given to the audible phenomena 
of the healthy or diseased body. Only a few voices — that of the 
often-mentioned Hooke more than any other (second half of the 
seventeenth century) — were timidly raised, and these were not heeded. 
Only in consequence of the discovery and general consideration of the 
value of percussion was auscultation developed, and this by Laennec, 
the discoverer of the stethoscope. His epoch-making work is called 

1 See under Percussion of Stomach. ^ See Percussion of Liver. 

3 See Examination of the Heart. * See Examination of the Heart. 



EXAMINATION OF THE RESPIRATORY APPARATUS. I I9 

Traite de V Aiisadtation mediate et des Maladies des Poumons et du 
Cceur. After him, Skoda, by critical sifting and by his own efforts, 
which traced the new phenomena to their physical causes, rendered 
imperishable service to this branch of knowledge. But up to the 
present time the work has still been going on, which, in part, has made 
new discoveries, and, in part, has investigated the nature of what was 
already known. 

The sphere of auscultation — of listening — in its widest sense extends 
to all that we are able to take note of by the ear, hence, in the first 
place, to the voice, cough, sounds caused by breathing, by mucus in the 
upper air-passages, which may often be heard in the farthest corner of 
the sick-chamber. But, strictly speaking, auscultation concerns only 
those phenomena which the ear perceives, either by direct application 
to the body or which are brought to it by an instrument, as a stetho- 
scope or an ear-trumpet. These, so far as they refer to the respiratory 
apparatus, form the subject of the following section. 

2. Methods of Auscultation. — Nowadays we employ both the 
immediate (direct) and the mediate (indirect) auscultation. In the first 
the ear is directly applied to the person to be examined ; in the latter 
we employ a stethoscope or ear-trumpet. While, as will be referred to 
later, we employ almost exclusively the indirect method in examining 
the heart and vessels, both methods are applied in the examination of 
the respiratory apparatus, and particularly of the lungs. In applying 
both, where it is possible we must endeavor to have the body bare ; in 
no case should the covering be more than a single thickness, and that 
should be as thin as possible and must be perfectly smooth. 

The application of the ear to the body consists simply in laying the 
ear lightly over the particular part to be examined. In order to place 
the ear exactly over the spot which we wish to auscult, it is well to 
place the tip of the index finger at the point and keep it there until 
the ear is placed at the point indicated, when the finger is withdrawn. 
For stethoscopic auscultation, in Germany at the present time, prefer- 
ence is almost universally given to the simple hollow stethoscope, 
the tube being about twelve to eighteen cm. long, with a not too small 
ear-plate. No doubt the plate has this disadvantage — unless the 
examiner is sufficiently careful — that it does not lie smoothly upon the 
outer ear; but, nevertheless, it is the most suitable form, since the 
stethoscope with hollowed ear-pieces, especially those recently devised, 
which, embracing the head of the auscultator, lie over the whole outer 
ear, for most persons have a most disturbing roar — a disadvantage 
which quite outweighs the advantage that, by increasing the resonance, 
it so well conducts the noises from the body ; and the cone-shaped 
ear-pieces which are inserted into the outer ear in the short stetho- 
scopes with stiff tubes cannot long be borne by the examiner. These 
short stethoscopes may have the further pecuharity that the end that 
rests upon the body measures, on the average, not more than two to 
five cm., hence they conduct to the ear impressions of sound from a 
much smaller region than will be heard from by direct auscultation. 
They are made of various materials (wood, hard rubber, ivory), but this 
is of small importance. Th.^. flexible stethoscopes (rubber tubing instead 
of the stiff tube, and ear-cones instead of the ear-plate) come less into 



I20 SPECIAL DIAGNOSIS. 

use because it is difficult, at least in the beginning of their use, to 
exclude the marked noises that are associated with them. Of the 
do2Lblc stethoscopes I only mention that of Camman. Though some- 
what complicated, it is very useful when one has learned to disregard 
the accessory sounds, which it intensifies as well as those one wishes 
to listen to. 

In general, the use of the stethoscope resembles the practice of 
percussion in that every one, especially while learning, ought always 
to use the same kind of instrument, in order that they may learn to 
judge correctly of the auditory impressions which the instrument 
furnishes. In my teaching I have always found that those students 
who each time they wish to make an examination had to borrow an 
instrument from their fellows did not hear anything. 

There are a large number of forms of stethoscopes, especially of the 
hollow stiff ones, the separate models of which it is not possible to describe. 
It may be remarked that the microphone has recently been employed. 

[By the use of a solid — a wooden or hard-rubber — stethoscope, 
referred to below, it is not absolutely necessary to remove the cloth- 
ing; by pressing the instrument firmly against the chest with the 
fingers friction of the clothing is prevented. 

The phonendoscope, devised by Bianchi of Florence with the assist- 
ance of Bozzi,^ marks a great advance in the means of auscultation. Its 
field of application is rapidly widening. By its aid minute changes are 
readily made out which before its use were not suspected. The contour 
of organs can be distinctly mapped out. — Trajislator?^ 

P. Niemeyer's solid stethoscope with ear-cones (acuoxylon) is deci- 
dedly not to be recommended ; it has not proved practical, nor are the 
theoretical grounds of its construction sound. 

It is very important in the beginning not to make pressure with the 
stethoscope. This must be considered particularly if, as it is often 
desirable to do, one removes his fingers from the stethoscope after 
having applied it to the desired place, and then holds it in place by 
means of the ear. However, in order to distribute the sHght unavoid- 
able pressure a rubber ring may be used, which is drawn over the foot 
of the stethoscope. The ring must be frequently renewed. But with 
proper care it may be entirely dispensed with. 

As was said above, it is decidedly to be recommended in the exam- 
ination of the lungs to employ both direct and indirect auscultation. 
The former is here preferable, since by it we can generally Hsten at 
one time to a large region of the lung ; hence it is, on the one hand, 
more comprehensive, and, on the other hand, furnishes collectively 
louder sounds. Moreover, in the examination of the chest posteriorly 
of very sick patients it cannot be dispensed with, since by its compre- 
hensiveness it furnishes the means of conducting the examination 
with the necessary quickness. On the other hand, the stethoscope is 
employed — 

1. Where the ear cannot be applied, as over the supraclavicular 
spaces. 

2. If we wish to listen quite separately to noises existing in a narrow, 
limited space. 

1 Medical Record, N. Y., Oct. 31, 1896, p. 624 f. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 121 

3. Sometimes, from reasons of delicacy, as over the female breast. 

4. If the physician wishes to avoid being soiled, or the risk of receiv- 
ing or getting parasitic insects or infections. 

In a general examination it is well to auscultate after percussing. 
After percussing the front of the chest, auscultate over the same re- 
gion, and then percuss and auscult the back. Generally the patient 
should breathe deeply; it is not at all preferable to have him breathe 
very hard and quickly. Not infrequently we hear best with mode- 
rately deep breathing. Where it is possible, as in percussion, sym- 
metrical parts should be compared. The particular points where it is 
necessary to take care are described in the following section. 

3. Auscultatory Signs in Normal Respiration. — i. Bron- 
chial Breathing. — If we auscult the larynx or trachea of a healthy 
person during inspiration and expiration, we hear a loud aspirating 
sound which corresponds somewhat exactly with that we can make 
with the mouth when we put it in position to pronounce h or ch, and 
then inspire or expire. We designate this sound as the laryngeal and 
tracheal, or by the collective expression bronchial, breathing, sound. Its 
peculiarity is its more or less pronounced sharpness (cJi or h sound), 
and moreover a somewhat rising pitch ; again, it is ordinarily some- 
what louder (and deeper) in expiration than during inspiration. The 
sound is formed in the glottis by the eddies which are here formed in 
the current of air by the sudden narrowing ; it is louder in expiration, 
because the rima glottidis is narrower then than during inspiration. 
The strength and rapidity of the breathing have a great influence upon 
the loudness of the sound. 

Besides over the throat in front, where the larynx and trachea lie 
superficially, we hear this sound over the vei'tebra proniinens at the 
back of the neck in healthy persons during moderately strong breath- 
ing ; also, sometimes, over the upper part of the sternum ; very fre- 
quently, too, in the interscapular space, and more plainly at the 
right than to the left of the median line (region of the bifurcation). 

Bronchial breathing may be noticed at other parts of the thorax at 
a varying distance from the above regions during strong breathing, 
especially with violent, coughing expiration. It is heard earliest over 
the upper sections of the chest. There may be great individual differ- 
ences, and yet be within the limits of the normal. Confounding bron- 
chial breathing with the diseased conditions to be mentioned later will 
be avoided by noting the approximate symmetry of this breathing 
sound, the condition in feeble breathing, and also the result of the 
further examination. 

A noise which arises in the pharynx and at the lips of the person 
examined not infrequently disturbs or deceives the beginner : closing 
the free ear is here recommended. 

2. Vesicular Breathing. — In healthy persons this is heard whereso- 
ever the lungs lie in contact with the chest-wall (with the exception of 
in the interscapular space).^ It is of a very slight shuffling character, 
resembling the sound we may produce by placing the lips in position 
to say / or v. The pitch of this sound can only be approximately 
recognized (like the clear non-tympanitic sound). 

^ See above. 



122 SPECIAL DIAGNOSIS. 

This sound can only be heard in inspiration, and most plainly at 
the end of inspiration. In a sound lung expiration has a very slight 
breathing sound which may be said to be of bronchial character. Not 
infrequently it is wholly imperceptible ; sometimes, however, we find 
inspiration which is simply like a very much weakened vesicular 
inspiratory sound. 

The force of vesicular breathing varies very much. It is most 
determined by the strength of the breathing : in very strong respira- 
tion it is often so loud that it is also heard over the organs adjacent to 
the lungs, as over the heart, liver, and stomach. In the majority of 
healthy persons the vesicular murmur is louder upon the left side than 
upon the right (Stokes). Otherwise, the strength of this breathing 
sound is determined by the loudness of the pulmonic sound : over thin 
portions of the lung, as the apices, it is very sHght, and likewise it may 
be weakened by the thickness of the covering, even to such a degree as 
not to be heard at all. Moreover, there are individual differences 
which depend chiefly upon the differences in the width of the glottis^ 
also on the elasticity of the chest on the one hand, and on that of the 
lungs on the other. 

Puerile Breathing (Laennec). — The vesicular murmur in children is 
remarkably different from that of maturity ; the former up to about 
the twelfth year of age exhibits a remarkably distinct, loud, and sharp 
vesicular breathing sound, which approaches bronchial breathing, 
especially also in that often it is nearly as strong in expiration as in 
inspiration. Generally, also, women have a stronger vesicular murmur 
than men. 

Origin. — Since Laennec different hypotheses have been advanced to 
explain the origin of the vesicular sound of respiration. As yet there 
is no unanimity among those who have given attention to the question. 
Formerly, the explanation of Baas and Penzoldt was accepted. Accord- 
ing to this explanation, the vesicular sound represents the laryngo- 
tracheal breathing^ sound transmitted through the air-containing lungs. 
The laryngo-tracheal breathing sound in passing through the inflated 
lung-tissue is toned down to the fineness and lightness of the vesicular 
sound. Thus it is quite plausible that vesicular breathing is distinctly 
audible during inspiration, when the current of air is directed from the 
larynx and trachea toward the ear, but is almost inaudible during 
expiration, when the current is reversed. It is, further, very evident 
that the vesicular sound gives way to the unchanged or slightly 
unchanged laryngo-tracheal sound, " bronchial breathing," as will be 
explained farther on, whenever the lung-tissue intermediate between the 
ear of the auscultator and the bronchi does not contain air in conse- 
quence of infiltration (pneumonia), or severe compression (pleuritis 
exudativa), or where there exists a massive tumor, with compression of 
the pulmonary tissues between the ear and the bronchial tree. In 
regard to cavities the conditions are slightly different.^ 

Lately, however, objections have been made to this theory by 
persons worthy of notice (Dehio, Sahli), which objections necessitate a 
re-examination of the question. Sahli, particularly, thinks it is beyond 
all doubt that vesicular breathing is produced entirely by the respira- 

1 See above, p. 121. ^ See these. 



EXAMINATION OF THE RESPIRATORY APPARATUS.^ 1 23 

tory movements of the parenchyma of the lungs. We cannot here 
discuss the pros and cons of the question, but we emphatically cannot, 
from very weighty reasons, coincide with the authors last mentioned. 
We consider vesicular breathing to be tubular breathing, which by 
being transmitted becomes toned down and weakened. But this is true 
not only of the breathing sound which is conducted from the larynx 
and trachea, but also of that from the medium-sized, the small, and the 
smallest bronchi. Every current of air, even in the smallest bronchial 
branch, causes vibrations and must produce a bronchial sound. This 
sound, together with that of the larger bronchi, of the trachea, and of 
the larynx, modified by the air-containing lung-tissue, is what is heard as 
vesicular breathing ; but when slightly or not all altered by solidified 
lung-tissue or other dense media, it is heard as bronchial breathing of 
different qualities. 

From this it is seen that now, as formerly, we think the explanation 
of Baas and Penzoldt the more correct one. There remains only to 
be noticed as an essential modification of this theory that there exists 
an independent bronchial breathing, even in the smallest bronchi, if air 
passes through them, and that this bronchial breathing reaches the ear 
as vesicular breathing. 

Sometimes there are special peculiarities of vesicular breathing quite 
within the normal, which may easily mislead the beginner. During 
inspiration we may see interrupted or jerking respiration in persons 
who, at discretion, take deep breaths imperfectly, in a jerking manner ; 
and, further, in whining children, who half suppress their sobs. This 
kind of jerking breathing exists over all portions of the lungs alike. 
Moreover, in the portion surrounding the heart, and as far up as to the 
apex of the left lung, the vesicular murmur exhibits interruptions 
exactly corresponding to the action of the heart (systolic vesicular 
breathing, depending upon the unequal entrance of air into this portion 
of the lung in consequence of the changed volume of the heart, and 
hence often especially plain in disturbed heart's action). 

To learn to distinguish between the bronchial and vesicular 
breathing is, for the beginner, among the most difficult things in diag- 
nosis. For the comprehension of the latter sound it is strongly recom- 
mended always to auscult directly, since the sound is then louder and 
its nature can thus be more clearly recognized. More than this, it is 
well to place the ear frequently, for comparison, upon the patient's neck, 
so as there to hear the bronchial sound. 

4. Pathological Sounds in the Respiratory Apparatus. — 
The following are enumerated : 

(ci) Changes in vesicular breathing. 

{b^ Bronchial breathing, in place of vesicular breathing. 

(c) The so-called indefinite, transition breathing [broncho-vesic- 

ular]. 

(d) Dry rales. 

(e) Moist rales. 
J/) Crepitant rales. 

g^ Friction-sound of the pleura. 
(K) Succussion-sound of Hippocrates. 
From this enumeration, and still more from what follows, it is 



124 SPECIAL DIAGNOSIS. 

evident that the number of pathological sounds to be heard with the 
diseases of the respiratory apparatus is not small. The chief difficulty 
is that very often different ones are to be heard at the same time, so 
that one sound conceals another. It is urgently recommended that 
the beginner at first practise in such a way that, in auscultating, he 
endeavor always in the first place to learn to recognize only the 
breathing sound, and that he then endeavor to direct his attention to 
other possible so-called accessory sounds (rales, friction-sounds). One 
can acquire the power to exclude one sound in order to be able more 
exactly to pay attention to another — to acquire a certain aural dex- 
terity which very much facilitates auscultation. 

(a) Alterations of Vesicular Breathing. — i. The vesicular breath- 
ing sound may be increased in inspiration, or sharpened. This takes 
place whenever the respiration is increased, as in active deep breathing ; 
in the acme of Cheyne-Stokes' breathing ; in certain forms of dyspnea, 
as of diabetic coma ; and where one section of lung is vicariously per- 
forming the work of others which have been shut off. 

Moreover, it forms a very important sign in bronchitis, here occa- 
sioned by the local narrowing of small bronchial tubes in consequence 
of swelling of the mucous membrane and accumulation of mucus. Not 
infrequently beginning tuberculosis of the apex is revealed solely by 
sharpened vesicular breathing in comparison with the sound side, as 
evidence of accompanying catarrh of small bronchial tubes. 

Here the one-sidedness of the sharpened vesicular breathing is of 
the greatest importance ; two-sided sharpened breathing of the upper 
portion of both lungs almost never has this signification ; not infre- 
quently it exists in tightly-laced women, also in children who breathe 
poorly with the lower portions of the lungs in consequence of a high 
position of the diaphragm, due to abdominal affections. 

2. Vesicular breathing may be diniinislied, either in bronchial catarrh 
in case the entrance of air into a section of lung is notably diminished 
by the swelling and secretion, or if bronchial branches are more or less 
closed by foreign bodies or compression. Diminished breathing of a 
portion of lung is also a consequence of pleural tJdckening and of 
many conditions which give pain in respiration, manifested by the less- 
ened, weakened breathing of the affected side. Diminished inter- 
change of air everywhere, and hence a two-sided extensive weakened 
breathing exists in emphysema, also in stenosis of the upper air-pas- 
sages. All thickenings of the chest-wall (tumors, etc., edema) weaken 
the respiratory sound by rendering the conduction more difficult ; and, 
finally, marked weakening develops rapidly with pleural exudations, 
both on account of the diminished breathing and the more difficult 
propagation of the breathing sound by the layer of fluid. 

In all these cases the breathing sound may even completely dis- 
appear ; most frequently is this the case with pleural exudations, also 
in complete closing of a large bronchial branch, but it may exist even in 
emphysema. 

3. Prolonged expiration. This occurs when the exit of the air from 
the alveoli is more prolonged than is normal, and this condition may 
be dependent upon diminished elasticity of the lung-tissue : emphysema 
or bronchitis — a certain degree of bronchial narrowing, which does not 



EXAMINATION OF THE RESPIRATORY APPARATUS. 1 25 

hinder the entrance of air, but only its exit. Of these two conditions, 
prolonged expiration is an important diagnostic mark, and here, again, 
especially comes into consideration bronchitis which accompanies the 
commencement of tuberculosis of an apex of the lung. The prolonged 
expiration of bronchitis is also generally sharpened, more markedly 
aspirant, somewhat more distinctly bronchial, than normal. With pro- 
nounced bronchial expiration thickening may be conjectured to have 
taken place.^ 

4. Jerking inspiration may likewise be a sign of bronchitis — namely, 
in case the two conditions are excluded which, within the normal, 
cause these or a like phenomenon.^ This pathological jerking respira- 
tion, according to its prominence, is confined to the region of the bron- 
chitis, generally to an apex, as in phthisis, and thus is distinguished 
from the interrupted inspiration of awkward breathing ; but it exists 
always at the beginning of the examination. It results from the de- 
layed entrance of the air into the lung portion of the bronchial tubes if 
these are narrowed by catarrh. 

It takes place with sJiarpened and with, jerking breathing and breath- 
ing witJi prolonged expiration, since in the majority of cases it is called 
forth or is accompanied by bronchitis — generally, also, toneless rales.^ 

{b) Bronchial Breathing. — In order to understand the pathological 
development of this respiratory sound, it first is of the greatest import- 
ance that it should be made clear how the respiratory sound normally 
at the glottis, in the trachea, and in all the bronchi exists as a bronchial 
sound, how it is further conveyed by the subdivided columns of air in 
the bronchial tree as a bronchial sound, and how in healthy persons it 
is deadened by lung-tissue normally containing air into the vesicular 
breathing sound. There is no breathing sound without open bronchial 
tubes ; there is no vesicular breathing without lung-tissue containing air. 
If between the bronchi and the ear there is no air-containing lung- 
tissue, if anything at all is heard it is bronchial breathing. 

Pathologically, bronchial breathing occurs in thickening of lung- 
tissue of a certain extent — that is, in case it involves an extent that 
reaches as far as moderately sized bronchial tubes. Here belong acute 
and chronic pneumonia, infarction, under some circumstances new 
formations, and also compression of the lungs, so that the air is expelled 
by a correspondingly large pleuritic exudation (this is generally near 
the upper posterior boundaries), of by tumors of any kind in the chest- 
cavity, or by very high position of the diaphragm. 

In pneumonia, if a considerable number of bronchi become ob- 
structed with fibrinous exudate and mucus, and they thus become 
completely impassable, they cannot conduct any sound of bronchial 
breathing. Therefore, in such cases simply no breathing sound at all 
is heard. It may, however, suddenly appear when, after a fit of cough- 
ing, the bronchi have again become passable. 

It has been said that complete compression of the lungs by a large 
pleuritic exudate produces bronchial breathing. Something more must 
be added to this statement : If the amount of exudation be small, 
it does not so fully compress the lungs as to expel all the air, but it 
only produces retraction of the lungs, and the respiration remains 

^ See below. ^ See above, p. 123. ^ See below. 



126 SPECIAL DIAGNOSIS. 

vesicular. However, if the exudation be abundant, it may even com- 
press the bronchi, and that, together with the mass of the Hquid, has 
the effect of cutting off all respiratory sound.^ 

If a pneumonia is combined with a stopping of the bronchial tubes 
(mucus, fibrin), then, on account of this imperviousness, we do not 
hear anything, but after a cough the bronchial tubes may become 
pervious : there is bronchial breathing. 

Moreover, Ave hear bronchial breathing over huig-cavities and in 
open pneumothorax ; and, besides, over the former sometimes, over 
the latter always we hear it in the form of amphoric breathing? It is 
only when the cavity is near the surface that we have bronchial 
breathing over it, when it is surrounded by tissue that contains no air 
and is in open communication with a not too small bronchial branch. 
In both conditions the bronchial sound really arises from the fact that 
the air, flowing out of the bronchus that connects with the cavity, 
or which, connected with a pleural cavity, enters into a larger air- 
space, or out of this air-space again into a narrow bronchial canal, is 
set into whirling motion. But there is no doubt that, besides, the 
sound that is conveyed from the glottis joins with it as bronchial.^ 

In the cases just mentioned the bronchial breathing sound, under 
various circumstances, may become weakened — namely, either when 
the advance of the sound to the ear is made difficult or when the 
breathing is weakened. Thus, in consequence of the fluid which gen- 
erally lies between the ear and the compressed lung, a slight, distant- 
sounding bronchial breathing is characteristic of an exudative pleuritis 
("breathing of compression"); while, on the other hand, in croupous 
pneumonia, almost always there exists a very loud, sharp bronchial 
sound. But in pneumonia otherwise rare conditions in their turn may 
weaken the bronchial breathing ; in closure of the bronchial tubes, as 
was mentioned before, we hear low bronchial breathing or else nothing 
at all ; further, in the so-called central pneumonia it may happen that 
from the part of the lung containing air which lies superficially, a 
vesicular and, almost concealed by this, a low bronchial breathing 
sound is produced. Also, the loud pneumonic bronchial breathing 
may be weakened if the pneumonia is complicated with an exudative 
pleuritis. 

In all these cases the low bronchial sound is usually most distinct 
during expiration,* often even only perceptible in expiration as a weak 
ch kind of blowing. 

The broncJiial brcatliing of a holloiv space may be weakened or even 
lost — weakened in temporary narrowing or closing of the bronchus 
leading to it by mucus (hence, loosened by cough), or lost by the fill- 
ing of the cavity with secretion. On the other hand, a thick, callous 
pleura covering a cavity may rather be the occasion of deadness than 
that the bronchial breathing is affected. 

Special forms of bronchial breathing are the amphoric and the 
metamorphosing breathing. The former exists with very large, smooth- 

^ [Compare these two paragraphs with what is said later regarding increased vocal 
fremitus. — Translator'^ . 

2 See Amphoric Breathing. ^ See Amphoric Breathing. 

* Compare what was said above regarding Expiration. 



EXAMINA TION OF THE RESPIRA TOR Y APPARA TUS. 1 2/ 

walled, communicating cavities and in opeit pneumothorax} It is a 
bronchial sound with metallic tone, exactly analogous to the metallic 
percussion sound that arises by resonance in large smooth-walled 
cavities. 

Amphoric breathing, moreover, may be found in open pneiimotJwrax 
(and where there is valvular connection), also in closed, although more 
rarely and only very softly, since here the (bronchial) sound of the air 
flowing into the trachea acquires a resonance in the air-containing pleu- 
ral cavity ; Hkewise, rales, heart-sounds, may acquire a metallic tone. 

Metallic associated soiuid may also, in rare cases, accompany unde- 
fined — that is, bronchial — breathing unnoticeably weakened ; thus also, 
not rarely, in pneumothorax. It might, indeed, be suitable to desig- 
nate it not as " amphoric," but as " undefined, with metallic associated 
sound." 

Metamorphosing breathing (Seitz). In this the inspiration is divided: 
it begins distinctly bronchial, like the sound of stenosis, and suddenly 
changes to a weak bronchial breathing, which is then also heard 
during expiration. This phenomenon is very rare ; it is said to be a 
sure sign of cavity (?). It is explained that the bronchus leading to the 
cavity is always first narrowed, and in the second part of inspiration it 
becomes dilated by the current of air. We too have the metamor- 
phosing breathing only over cavities ; but in such circumstances the 
cavities were always so large that they could be diagnosed also from 
the remaining phenomena. 

{c) Undefined Breathing. — The breathing sound may in two ways 
be of such a character that it may be designated either as distinctly 
vesicular or as distinctly bronchial. First, it may be so weak that its 
character remains indistinct, concealed or drowned by other sounds, 
particularly by rales ; or, while it can be heard, it does not entirely 
correspond to either type of breathing, but seems rather to stand 
between the two, thus sometimes inclining more to bronchial, at other 
times more to vesicular, breathing — " transition breathing," *' hinted or 
indistinct bronchial or vesicular breathing," " sharp breathing with 
bronchial breath in expiration," etc. 

The causes of what is included in the first category are very various.^ 
Of course, the examiner's sharpness of hearing is an important factor 
here. Rales that may be present may frequently be removed or 
diminished by coughing strongly. 

The second group of undefined breathing is, of course, much more 
numerous with beginners than with those who are practised in auscul- 
tation. It is well, however, for the latter also to impose upon them- 
selves some reserve in pronouncing whether it is vesicular or bronchial. 
The determination is often actually possible either by the tone itself or 
by the strength of expiration in relation to inspiration. Frequently 
also, as in beginning phthisis, in various lobular pneumonic deposits, the 
physical conditions resulting from the pathologico-anatomical changes 
cause it to appear that there is a "transition breath" — that is, a min- 
gling — in that the infiltrated part of the lung favors the transmission of 
the bronchial sound unchanged, while the parts containing air convey 

^ See the preceding page. 

2 See -what was said above concerning the strength and weakness of the breathing sound. 



128 . SPECIAL DIAGNOSIS. 

the breath-sound to the ear toned down to the vesicular sound. Hence, 
under no circumstances can we miss this idea of " transition breathing," 
and it is best in such cases simply to describe the breath-sound. 

{d) Dry Rales (Rhonchus, Humming, Whistling, Hissing). — Like 
all rales, these are pathological sounds. They appear when there is a 
bronchial catarrh, which furnishes a tough, scanty secretion. They 
constitute those audible phenomena that are caused by the rushing 
together of the air and secretion in the bronchial tubes. It is as diffi- 
cult to make a sharp distinction between a " tough " and a " fluid " 
secretion of the bronchial tubes as in a stricter sense it is to separate 
the so-called " dry " from what is later referred to as '* moist " rales — 
much more, since transitions are everywhere present. Meanwhile, 
however, the class of sounds here referred to take a somewhat special 
place, both on account of the auditory impression they make and be- 
cause they exactly correspond to the very toughest bronchial secre- 
tions. The humming, hissing, whistling sounds (sonorous, sibilant 
rales) arise from the fact that the bronchial air-passage is narrowed by 
the swelling and the mucus, and hence they are sounds of stenosis ; but, 
besides, some of the very fine high hissing and whistling tones may be 
caused by the presence in the bronchial lumen of tense threads of 
mucus stretched across, which, like the strings of an Eolian harp, are 
blown upon by the current of air. 

Sibilant rales very often have such a high musical tone that it can- 
not be deadened even by the air-containing lung. Under some circum- 
stances they may be confounded with the so-called ringing rales 
[m.etallic rales]. 

The dry humming often shows unnoticeable transitions to the cha- 
racter of the sound of the moist rales, approaching more nearly to 
crepitation. According to my view, they may still as dry, become 
ringing, rales — that is, may exhibit a ringing character like bronchial 
breathing. This is the case when we have thickening of the lungs and 
at the same time bronchitis with tough mucus.^ 

The humming, hissing, whistling may be abundant or scanty, loud 
or soft. It may occupy the whole time of inspiration and expiration 
and completely conceal the breath-sound, or it may only be heard at 
the end of inspiration. A very fine soft whistling is sometimes heard 
during the whole of expiration, since then, so far as vesicular breathing 
is concerned, the breath-sound is very soft. When they are very loud 
the sounds may even be heard at a distance (a distinguishing peculiarity 
of emphysema). Finally, there are buzzing sounds in the chest which 
may be felt when the hand is applied to it. Cough has sometimes the 
effect of diminishing, and sometimes of increasing, them — at least the 
humming is generally very markedly changed by it. 

It is not possible easily to confound the humming sounds with 
pleuritic friction sounds.^ On the other hand, I have not infrequently 
found that a very soft, fine humming was mistaken by beginners for 
sharp, even bronchial, breathing sound. This, as well as the distin- 
guishing of whistling and hissing from a peculiar ringing rale, can only 
be learned by practice. 

Conclusions. — Humming, whistling, hissing sounds, as has been 

1 See ringing rales, under Moist Rales. ^ See p. 132. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 1 29 

shown above, indicate a dry bronchial catarrh. Spread over the lungs, 
they are present with diffuse bronchitis with tough secretion, whether it 
occurs independently or as an accompaniment of empliysema, in which 
disease they are almost never wholly wanting. In these cases the 
lower lobes of the lungs are generally the seat of the catarrh. When 
there is simply bronchitis, then these rales and a sharpened or 
weakened breathing are the only local physical signs of disease. In 
emphysema the percussion and auscultatory signs of this condition are 
also present. Localized dry rales exist as signs of catm^h of the apices, 
which accompanies commencing tuberculosis : here, for example, a low 
whistling in a perhaps somewhat prolonged expiration may for a long 
time form the only symptom. Ringing dry rales are rare ; they are 
most frequently heard in pneumonia at the beginning of the second 
stage. 

In all these cases the dry rales may be combined with the moist.^ 

{e) Moist Rales. — These arise in the bronchial tubes, except the 
smallest, and in the pathological cavities of the lungs [vomicae]. 
Their production requires more or less fluid secretion ; the more fluid 
there is the more moist the sound ; if it is tougher, then there are 
" viscid-moist " rales, a transition to the dry. Generally, the ear 
directly receives an impression of a greater or less degree of moisture. 

Formerly moist rales were explained as being produced by the 
bursting of bubbles which the current of air caused upon the surface 
of the fluid. More recently they have received another explanation : 
according to the analogy of the bubbles which we see formed when 
we blow through a tube one end of which is immersed in water, it 
is supposed that the current of air separately moves the air-bubbles 
which present projections into the bronchial tubes, and that as one such 
quantity of air breaks the bridge through the fluid and advances, the fluid 
behind it, immediately rushing on again and occupying the space, shares 
the vibration in the pent-up air : crepitation rales (Talma, Baas). It is to 
be added that many consider moist rales in part due to stenosis ; and, 
finally, that it is said that the to-and-fro motion of the secretion pro- 
duced by the current of air causes rales (Traube). The explanation by 
Talma and Baas will serve very well for the rales formed in the 
medium-sized bronchial tubes ; for vomicae it only serves in case the 
bronchial tubes leading thereto are immersed in the fluid secretion, 
which, indeed, is ordinarily not the case. Here, and with large 
bronchial tubes at any rate, we must think of bursting bubbles. 

Moist rales may be so numerous that they can be heard in both 
inspiration and expiration, even outlasting the expiration. If they are 
scanty, then we are apt to hear them during inspiration, under some 
circumstances only toward the close of inspiration. A slight cough 
may increase them, or cause them in case they were for the time being 
absent. 

In cases where the rales are very scanty, scarcely to be heard, it is 
useful to inquire as to the time of day the cough is the most frequent, 
and to listen to them before the occurrence of the paroxysm of cough, 
so as to make the examination before the bronchial tubes have been 
cleared of mucus (as shortly after waking). 
1 Regarding these see below. 



130 SPECIAL DIAGNOSIS. 

The different moist rales make the impression upon the ear of being 
of different " sizes," and even beginners can without difficulty judge 
approximately whether they are found in a large or a small bronchus 
or cavity ; we speak of large, small, also medium-sized rales. The dis- 
crimination of rales in this respect is very important ; for instance, we 
may distinguish whether we have a bronchitis of only the large, or 
whether the smaller, tubes have become involved ; dangerous capillary 
bronchitis is manifested by very small, fine rales, and also by crepitant 
rales. ^ Large rales may furnish an index in the examination of the 
apices : these contain only very small bronchi ; hence, if in an apex 
there are large or only medium-sized rales, these cannot arise from the 
bronchi there ; hence there must be a pathological space — a cavity. If 
there are large rale-sounds which undoubtedly arise in the apex, they 
are a most certain sign of cavity. 

The loudness of the rales does not depend upon their number, but 
upon the strength of the breathing. But the loudness furnishes an 
indication of the place where they arise : ccEteris paribus, the sound 
will be loudest at the point where the ear is nearest to them. It 
may be of the greatest importance to locate them exactly. Here, 
again, the most striking example concerns the diagnosis of phthisis, 
and, too, of the ominous catarrh of the apex. By a superficial exam- 
ination it may easily happen to the inexperienced, especially in the 
examination of the back, that he locates rales which come from the 
neighborhood of the root of the lungs, and are those of a benign 
bronchitis, in the apex, and hence makes the diagnosis of phthisis. 

It is of the very highest value, but often not easy, to distinguish 
whether we have a ringing or (" consonant," Skoda) or a non-ringing 
rale-sound. The former is acoustically related to the latter, as the 
bronchial breathing sound is to the vesicular (as tympanitic percussion 
note to lung-sound), and, like that, ringing rales appear if there be 
present either a thickening of the lung of sufficient extent or if there be 
a cavity. But yet bronchial breathing and ringing rales, and vesicular 
breathing and non-ringing rales, are not always necessarily associated 
together; thus, not infrequently when there are small cavities, and 
even large ones, especially in the lower lobes, in case they are covered 
by a not very thick layer of air-containing tissue, we hear ringing rales 
when the breathing is undefined, yet hinting toward the vesicular. In 
children, even when there is no trace of cavity or thickening, in simple 
bronchitis the rales may reach the ear as loudly ringing (from the pro- 
nounced elasticity of the lungs and of the thorax). On the other hand, 
in pneumonia and pleurisy we sometimes hear bronchial breathing and 
non-ringing rales. 

But now, corresponding to " transition breathing," very frequently 
there are to be heard such rales as stand between the non-ringing and 
the pronounced ringing ("hinted" or slightly ringing rales). It is 
often difficult to interpret these. In general, with children they furnish 
no reason for the supposition of thickening or cavity more than with 
adults. 

Loud ringing, hinted ringing, and non-ringing rales are often found 
together ; we may even say that almost never do we hear ringing rales 

^ See p. 131. 



EXAMINATION OF THE RESPIRATORY APPARATUS. I3I 

alone at one place. But, of course, if they are present they predomi- 
nate. Though they exist very near together, yet they can be locally 
separated, as sometimes in emphysema ; here, with extensive humming, 
whistling, and non-ringing rales at a certain point of the lower lobe, 
there may be ringing rales (perhaps without bronchial breathing and 
without deadened or tympanitic resonance) : this makes a bronchi- 
ectatic cavity probable. But, also, by the same signs, in general bron- 
chitis a broncho-pneumonic deposit may be made known. 

As the ringing rales correspond to bronchial breathing, so in their 
manifestation the so-called metallic rales correspond to amphoric 
breathing (metallic percussion-note) ; but again in such a way that the 
two symptoms are not necessarily associated together. The metallic 
rales then occur in correspondence with very large, smooth-walled, 
superficially-located cavities, and also in pneumotJiorax, where, arising 
from sections of the lungs which are breathing (even if on the other 
side), they are to be regarded as rale-sounds in the air-containing 
pleural cavities endowed with resonance. 

Sounds of falling drops. These are often only separate, generally 
very much inflated, moist rales, which have a high metallic note ; 
sometimes, indeed, there is only one in each phase of the breathing ; 
then the above-mentioned designation of it serves. 

Water-whistling , or the sound of lung-fistida (Unverricht, Riegel). 
We thus designate a metallic rale or very fine metallic gurgling or 
splashing which occurs in open pneumothorax if the patient's position 
is such that the opening in the pleura is directly below the smooth 
surface of the fluid, and if the patient then draws a breath (first ob- 
served by Unverricht while puncturing and aspirating a case of hydro- 
pneuinothorax). 

(/) Crepitant Rales (Crepitation). —Briefly expressed, by this we 
understand the finest rale sounds. It occupies a special place on ac- 
count of its acoustic peculiarity, on account of its cause, which permits 
its classification either under the moist or under the dry rales, and, 
finally, on account of its special diagnostic meaning. 

The so-called atelectatic crepitation occurs in health, and still more 
in disease, over parts of the lungs which have for a time been breathing 
poorly and now are again distended by a full breath. Most frequently 
is it observed after quite long, especially low, dorsal position, over the 
lower parts of the lower lobes. It is purely inspiratory, and generally 
disappears after the first deep respirations. 

Like this are crepitant rales which are to be heard in croupous 
pneumonia during the first, and in the beginning of the third, stage 
(crepitatio indux and redux), sometimes in catarrhal pneumonia, more- 
over in pulmonary infarction, generally speaking in all kinds of consoli- 
dation, and, finally, especially in edema of the lungs. 

In all these cases we have to do with crepitation heard during 
inspiration, or, at most, only the beginning also of expiration, which 
occurs in very fine and equal-sized bubbles. It is well compared to 
the noise produced by rubbing a lock of hair between the fingers in 
front of the ear, or by separating the thumb and finger moistened and 
pressed together as they are held before the ear (Eichhorst). It arises 
in the smallest bronchial tubes, the alveolar spaces, and in the alveoli 



132 SPECIAL DIAGNOSIS. 

when these are collapsed and glued together or partly filled with 
secretion, and then during strong inspiration their walls are torn apart 
or freed from secretion. It is only in individual cases that this crepita- 
tion is heard in expiration and only in expiration (Penzoldt). 

The non-iuiifoinn crepitation, so called, forms the transition from 
these sounds to the fine bubbling rales. More than elsewhere it 
occurs with capillary bronchitis and also in edema of the lungs. It is to 
be understood as a mixture of peculiar crepitations and small bubbling 
rales, and accordingly, in its coarse sounds, it is to be heard also in 
expiration. 

{g) Pleuritic Friction-sounds. — The respiratory gliding of the 
pleura costalis upon the pleura pulmonalis, which normally is noise- 
less, is perceived by the ear, and can also be felt when the hand is laid 
upon the chest, when there are inflammatory deposits upon the serous 
surfaces. Thus it is really the pleuritis sicca that causes it. Only in 
rare cases of unevenness of the pleura is this phenomenon observed in 
the absence of inflammation, as in acute miliary tuberculosis of the 
lungs and pleura ; also in pneiimonokoniosis. The conditions most 
favorable for the occurrence of this sound are where the respiratory 
movement of the lungs (forward and downward) is most marked — 
below and especially at the sides. But this sound may also exist 
farther up, even almost as high as the apices. 

Pleuritic friction-sounds are like regular scraping or like a scratch- 
ing, creaking, beginning in distinct pauses, which ordinarily are louder 
during inspiration than expiration. Not only can they be heard, but 
they can be felt, only weaker : " palpable friction-sounds," best recog- 
nized by the laying on of the flat hand. This friction-sound is not 
changed by cough, but continued deep breathing often causes it to dis- 
appear, since in this way the unevenness, upon which it depends, is 
smoothed out. 

When this friction-sound is very loud and characteristic it is easily 
recognized. A difficulty may arise when it is very softly heard ; this 
often occurs from the fact that the examiner does not auscultate at the 
right spot, for friction-sound is heard in only a circumscribed area, 
since it is poorly transmitted. A further difficulty lies in distinguishing 
it from certain medium-sized, tough, moist rales (cracking rales) and 
from soft buzzing ; here it is most important to take note of the 
character of the particular sound, and the knowledge and recognition 
of this can only be acquired by practice. We may make use of the 
effect of coughing as an aid. Sometimes moderate pressure with the 
stethoscope increases the pleuritic sounds ; also, palpation may help us 
to recognize them. Rale-sounds are seldom, or, at most, only slightly 
to be felt. It is to be remembered that friction- and rale-sounds may 
occur at the same time. Besides, in pneumonia, I have observed this 
most frequently in disseminated tuberculosis and in caseous pneumonia 
of the lower lobes. 

Friction occurs with all kinds of pleuritis. It occurs (seldom) in 
acute exudative pleuritis in the beginning of the attack, and also later 
as a favorable sign with the absorption of the fluid exudation. There 
can be no friction-sound while there is fluid present, since it is only 
heard when the pleural surfaces are in contact. In chronic pleuritis it 



EXAMINATION OF THE RESPIRATORY APPARATUS. 1 33 

may last indefinitely and over a large extent. Of the diseases of the 
lungs which usually are accompanied by pleuritis sicca, many are first 
revealed by the friction-sounds which the latter causes : thus, phthisis^ 
also pyemic deposits in tJie lungs, infarction, bronchiectasis with reactive 
pneumonia, and pleuritis with emphysema. 

Regarding pleuro-pericardial friction-sounds (pericarditis externa), 
see under Auscultation of the Heart. 

{Ji) Hippocratic Succussion. — This is a phenomenon very easy to 
understand : 

In sero- and pyopneumotJiorax, after a strong shaking of the chest, 
as in any vessel partly filled with fluid, there is splashing. This 
splashing, through the resonance associated with metallic tone, like 
all the audible phenomena of pneumothorax, is heard at a distance 
or by applying the ear to the chest. 

This sign is usually most distinctly manifest when there is a small 
effusion and when it is serous. It is almost pathognomonic of hydro- 
pneumothorax in that it only elsewhere occurs in very isolated cases 
of large cavity with quite fluid contents. 

The direction of Hippocrates was to shake the patient by the 
shoulders, but, on account of the grave condition of most of these 
patients, the greatest care is necessary. Many quickly learn to shake 
the body so as to produce the sound themselves. 

Confounding this with the splashing from the stomach or colon will 
be avoided by local examination of these organs and by repeated 
examinations. 

Palpation of Vocal Fremitus (Auscultation of the Voice). 

Strictly speaking, this method of examination belongs in part to 
Palpation and in part to Auscultation, but at the same time it has a 
place here, because this comes next in the course of a thorough exam- 
ination of patients. It is, besides, of sufficient importance in itself to 
be treated separately, because, after Inspection, Palpation, Percussion, 
and Auscultation have been completed, not infrequently it happens that 
this casts the decisive vote. 

The vibrations of the glottis in phonation (speaking, singing, 
screaming) originate in the column of air in the trachea and bronchial 
tubes rather than in their walls ; they traverse the lung-tissue, where, 
in case this is normal, they become considerably weakened, then the 
wall of the thorax and its coverings, and may be felt by the hand laid 
upon the chest as a whizzing : voice vibration, voice fremitus, pectoral 
fremitus (besides heard as indistinct humming)} 

TJie technique of this method of examijiing is as follows : While the 
patient counts aloud, say from thirty to forty or from ninety to one 
hundred, the hand is laid upon different parts of the chest. Generally 
we employ the palm of the hand, but for finer examination it is prefer- 
able to apply the ball of the little finger or the tips of the first, second, 
and third fingers. Practice of the method last mentioned enables one to 
dispense with auscultation of the voice. Differences of voice-vibration 
are distinguished by comparison of different locations, and particularly 

1 See p. 135. 



134 SPECIAL DIAGNOSIS. 

of symmetrical points. It is quite unnecessary in making this compari- 
son to apply both hands at the same time to the two sides of the chest ; 
the difference is much more distinctly felt if we examine with the same 
hand, first upon one side and then upon the other. 

In the case of female patients with a very soft voice or of children 
it is better not to have them count, but to continuously pronounce the 
palatal r. (Compare the following paragraph.) 

Within normal limits, vocal fremitus is stronger the stronger the 
voice ; it is very distinct when the voice is rough and deep, weak if the 
voice is high, and even not to be felt at all when the voice is high and 
thin (light), as is sometimes the case in women and children. The 
separate vibrations are felt more distinctly the richer and more pro- 
longed they are. The fremitus is stronger upon the right side of the 
chest than the left, probably because the right bronchus is the larger 
in diameter. It is, moreover, very noticeably influenced by the thick- 
ness of the covering (muscles, mamma, subcutaneous fat). 

There may be pathological conditions present upon one side that 
will not propagate the vibration of the voice so well as a normal con- 
dition would do, which may diminish or remove the vocal fremitus ; 
on the other hand, they may better propagate it — strengthen the vocal 
fremitus. 

Weakness or suppression of vocal fremitus occurs with pleuritic exu- 
dation (on account of the narrowing of the bronchial tubes from com- 
pression and on account of the encroachment of the fluid) ; with pneu- 
mothorax^ on the one hand, either on account of the poor conduction 
through the bronchial tubes of the retracted or the compressed lung, 
or, on the other, because it is not conducted through the air-cavity. 
(If, however, there should be growths on the pleural surfaces, even if 
only in the form of fine fibers, these ordinarily act as good conductors 
of vocal fremitus.) Finally, vocal fremitus is weak or suppressed with 
tumors of the pleura and all thickenings of the chest-wall (abscess, 
edema), and in closure of the bronchial tubes, since these are the most 
important means of propagating the oscillations (closure from mucus, 
masses of fibrin, foreign bodies, compression). 

Increase of vocal fremitus is observed — in pneumonia, since the 
solidified lun^-tissue is a better conductor than when it contains air ; 
for the same reason, sometimes when the lung is compressed against 
the thorax-wall ; above pleuritic exudation and generally posteriorly 
at the roots of the lungs ; and in cavities with open bronchus and 
small secretion, here partly by the good conduction of the sound and 
partly by consonance. 

Vocal fremitus is an extremely valuable means of distinguishing 
between pneumonia and pleuritic exudation. Yet it may, in rare cases, 
so far deceive as that in pneumonia, if the bronchial tubes are stopped 
by secretion, there is no increase of vocal fremitus ; it is even dimin- 
ished, and, occasionally, with complete filling-up of the bronchial tubes, 
may even disappear altogether. Under some circumstances after cough 
and expectoration, as after a cool bath, it may return. It is easy to see 
how various the result may be if pneumonia and pleurisy, or if a 
cavity and thickened pleural walls, are combined.^ 

1 Compare this paragraph with p. 126. 



EXAMINA TION OF THE RESPIRA TOR V AFPARA TVS. I 3 5 

In most cases, in my opinion, auscultation of the voice may be dis- 
pensed with where one is thoroughly trained in testing the vibration 
of the voice by palpation especially by using the tips of the fingers. 
It is of value sometimes in the case of stupefied patients and chil- 
dren who cannot be induced to count. In reality, its result is fully 
analogous to that of palpation. Normally, over the thorax we 
hear the voice of the person examined as an indistinct humming, 
which pathologically may be weakened or lost; but it may be 
strengthened to an extraordinary loudness (bronchophony), wholly 
under the conditions which correspond to those that influence vocal 
fremitus. 

We sometimes find a very marked bronchophony over those cavities 
where we hear amphoric breathing and metallic rales. Here, also, the 
bronchophony may acquire a kind of metallic quality (Laennec's pec- 
toriloquy. 

Egophony, " bleating voice," is a peculiar nasal, bleating pectoriloquy 
sometimes heard, with pleuritic exudations, in the neighborhood of the 
upper boundary of deadness. 

Auscultation of the whispered voice was introduced by Baccelli. He 
found that it was propagated by serous exudations of the pleura, but 
not by purulent, since the latter dispersed the sound-waves. In most 
cases this method must be considered as without value, since in large 
serous exudations with marked compression of the lungs we as often 
do not hear the whispered voice. We may recognize it in very small 
and fresh purulent exudations unconnected with thickening of the 
pleura. 

Palpation and auscultation of the voice of course cannot be made in 
all those cases where the voice cannot be produced, as in unconscious- 
ness and exhaustion, or when the patient is dumb (aphonic), or where, 
from caution, we do not wish to have the patient speak aloud, as in 
hemoptysis, peritonitis, etc. Scherwald has recently devised a new 
procedure, which can be recommended — plegaphonia, or auscultation 
during percussion upon the larynx or trachea. The vibrations pro- 
duced in this way take the place of those of the vocal cords during 
phonation, and this procedure is exactly synonymous with auscultation 
of the voice. 

Mode of Application.- — We have some one else place a large ivory or 
hard-rubber pleximeter upon the surface of the thyroid cartilage or 
upon the trachea, and percuss with a hammer (sometimes the patient 
himself can do both). The patient closes his mouth. By preference 
we auscult during expiration. Ausculting on the thorax, we hear the 
blows — I, over the sound lung, very markedly weakened (loudest over 
the apices), as if it were vanishing, not tympanitic, but with a cracked- 
pot sound ; 2, over infiltrated lung, very loud, tympanitic, with Win- 
trich's change of sound ; here, also, the ear has a sensation as if the 
blows were upon itself; 3, over an exudation, simply weak even to 
complete absence ; 4, over cavities, the same as over infiltrated lungs ; 
over large open cavities, very loud, "smiting; " 5, over pneumothorax, 
a metallic sound. 

On the reverse principle Gabritschewsky ^ has constructed a pneu- 

1 Berl. klin. Wochenschrift, 1890. 



136 SPECIAL DIAGNOSIS. 

matoscope. He auscultates the percussion of the thorax from the 
mouth. We have had no experience with the method. 

EXPLORATORY PUNCTURE OF THE PLEURA; DIAGNOSTIC 
STUDY OF THE FLUIDS OBTAINED BY PUNCTURING. 

I. Exploratory Puncture. 

Mode of Procedure. — For this small operation we employ either 
an ordinary large hypodermic syringe, or, better, a somewhat larger 
syringe holding two grammes, of the same construction, with a steel 
cannula somewhat stronger and about seven centimeters long. The 
instrument must of course be carefully disinfected before it is used, 
both for the safety of the patient and from the diagnostic standpoint. 
For making cultures and for vaccination experiments the whole 
syringe, but particularly the piston, must be absolutely free from 
germs. This can be approximately obtained in a syringe with an 
asbestos piston, which is very much used lately. Absolute security is 
not obtainable with these, but all other instruments which have been 
mentioned, and which can be perfectly sterilized, are too unpractical or 
too expensive. With the piston pushed in the needle is inserted in an 
intercostal space perpendicular to the surface, and then the piston is 
v/ithdrawn. If the point of the needle rests in fluid, this will rush into 
the syringe. 

Directly before making the exploratory puncture the patient must 
be placed in exactly the same position he is to occupy during the 
operation, then be carefully examined and especially percussed. 

In this way we may ascertain whether there is fluid in that portion 
of the thorax, and of what kind it is. It is especially appHcable in the 
diagnosis of pleuritis (more rarely in hydrothorax and hydropneumo- 
thorax). It is to be performed in the following cases : 

1 . WJien there is the slightest doubt zvhether there is pleuritis or not. 
In the first place, we have to consider the differential diagnosis between 
pneumonia, tumors of the chest-cavity, and tliickening of tlie pleura} In 
these latter conditions the syringe will draw out nothing at all, or, at 
most, only a drop of blood. If the exploratory puncture yields a pos- 
itive result, it has of course a definite diagnostic significance. If, on the 
contrary, it is negative, that does not positively prove that there is no 
liquid in the interior of the thorax. In the first place, one may have 
missed the fluid with the point of the needle. This easily happens 
when there is only a slight amount of extravasation imbedded between 
thickened tissue. Again, sometimes no fluid is obtained because it is 
very thick or contains flocculi of fibrin, and this of course is more apt 
to be the case the smaller the cannula used. 

With reference to these possibilities it is often advisable to repeat 
the exploratory puncture one or more times. It is important not to be 
discouraged by a fruitless puncture if there is suspicion of a secluded 
empyema. The operation, which is quite harmless if performed cor- 
rectly, can be repeated four or more times at one sitting. 

2. To detemnine the nature of the fluid contained in the pleural cavity. 
If the fluid withdrawn is quite or almost clear like water, if it contains 

^ Compare pp. 1 12 and 134, 



EXAMINATION OF THE RESPIRATORY APPARATUS. 1 37 

no material elements, if there is no effusion of fibrin and it contains 
only very little or no albumin, then the fluid is a transudation ; other- 
wise it must be regarded as an exudation. Again, the exudation may 
be serous, sero-fibrinous, sero-purulent, chylous, or chyliform, and, 
finally, it may be hemorrhagic. The purulent extravasations are either 
odorless or stinking, and in the latter case are ichorous or feculent. 

The chylous and chyliform extravasations are similar to the puru- 
lent ; they are, however, different from the latter in having a more 
milk-white color, and often also by accumulation of fat on the surface. 
The chylous extravasations take their origin from communications of 
lymphatic vessels or of the ductus thoracicus with the pleural cavity, 
as when they burst from over-distention (filaria disease). The chyli- 
form extravasations are transudations or exudations consequent upon 
carcinosis or sarcomatosis of the thoracic cavity. These extravasations 
contain great quantities of tumor-cells from fatty degenerations. Chy- 
lous and chyliform extravasations microscopically are very much alike ; 
chemically, they differ only by the circumstance that the chylous con- 
tains a demonstrable amount of sugar, while in the chyliform there is 
no sugar unless compHcated with diabetes. 

The inic7'oscopic examiitation always reveals some pus-cells in the 
serous and sero-fibrinous exudations. There are all stages of transition, 
from the serous exudate containing a minimal amount of cells to that 
which shows macroscopical, as well as microscopical, purulent contents ; 
but in practice it is only seldom that one is in doubt whether a fluid should 
be designated as purulent or sero-purulent. Transition forms are to 
be called sero-purulent. Moreover, it is to be noted that many old 
sero-purulent and purulent exudates have the peculiarity that they 
deposit a sediment within the chest-cavity, so that in the dependent 
parts of the pleura there is thick pus ; in the higher parts there is a 
more or less pus-containing fluid. In making an exploratory puncture 
in cases where the exudate has existed for a long time, especially in 
patients who have maintained a certain position for a long time, it is 
important to remember these facts and to puncture low down as well 
as high up on the thorax. 

The chylous and chyliform extravasations contain great quantities 
of fat-corpuscles, fat-cells, fat-containing leukocytes, and endothelia. 
In the chyliform fluid there are sometimes found carcinomatous and 
sarcomatous cells. However, it is only very seldom that a diagnosis 
of carcinomatous and sarcomatous pleurisy can be made from the 
quality of the exudation. There occur here serous, hemorrhagic, and 
the chyliform extravasations which have just been mentioned. A posi- 
tive diagnosis is never possible except when particles of the tumor — as, 
for example, when groups of cells in characteristic arrangement — are 
mixed with the fluid. Single cells do not furnish a positive indication. 
Considerable lumps consisting of cells of very different form and size, 
which give with iodin the glycogen reaction, are more particularly 
significant of carcinoma. 

In old pyemic pus and in extravasations which contain much fat 
cholesterin is often found in the form of the well-known plates (see 

The microscopical examination for micro-organisms by means of 



138 SPECIAL DIAGNOSIS. 

the cover-glass preparations of the fluid and its sediment under all cir- 
cumstances is an imperfect method. However, it gives the physician 
some conclusion, especially in purulent exudates, and sometimes even 
in serous, and hence it ought not to be omitted, especially where 
prompt action is required. Several cover-glass preparations should be 
made at the same time — one with simple anilin coloring, one with 
Gram's, one with the stain for bacillus tuberculosis. It not infrequently 
happens that these preparations furnish a picture which is confirmed 
by cultures. For instance, by the method of Gram only diplococci, 
or only staphylococci, or the tubercle bacilli (the latter very rare) are 
met with, or there are great quantities of different bacteria (ichorous 
exudate). 

The examination for actinomyces is only made by the microscopical 
examination of the granules : to make cultures is difficult and unneces- 
sary. 

But if one wishes to make a careful diagnosis with reference to the 
presence of micro-organisms, cultures and vaccination experiments are 
necessary. The latter are particularly advisable when tuberculosis is 
suspected, because by vaccination we may get a positive result, though 
the culture process may have been negative. Vaccination is made 
upon guinea-pigs. 

The results of the examiiiaiion for bacteria are in general the fol- 
lowing : 

Transudations are always found free from micro-organisms. 

Serous and sero-fibrinous exudates are likewise sometimes free from 
them, but more frequently the following micro-organisms are found in 
them: i. The staphylococcus pyogenes albus : pleuritis after typhoid 
fever, after croupous or broncho-pneumonia. 2. The streptococcus 
pyogenes : various kinds of pleurisy, and also in abdominal affections. 
3. Frankel's pneumococcus: metapneumonic exudations — that is, such 
as follow croupous pneumonia. I and 3 may also occur together. It 
is interesting to note, as was first shown by Levy, whose observations 
have been corroborated several times by us, that serous exudations 
need not necessarily become purulent from this species of cocci, but, 
on the contrary, may disappear without becoming purulent. 4. BacilH 
of tuberculosis are almost never found in the pleurisies of tuberculous 
patients. 

Empyemas may be entirely free from micro-organisms— a circum- 
stance which very strongly points to tuberculosis. Moreover, they 
may contain — and this is generally the case — the staphylococcus 
pyogenes albus, aureus, citreus, or the streptococcus pyogenes, or 
several of these cocci together. Empyemas containing only staphy- 
lococci not infrequently take a benign course. Metapneumonic 
emphysemas mostly contain Frankel's diplococcus, and very often 
only this, but sometimes also Friedlander's pneumococcus ; and under 
some circumstances there may be, besides Frankel's diplococcus, 
staphylococci and streptococci. The metapneumonic emphysemas 
with Frankel's diplococcus usually contain very thick mucous pus, 
which it is difficult to aspirate. They have a remarkable tendency to 
be spontaneously absorbed. 

Ichorous and feculent-ichorous exudations are always distinguished 



EXAMINATION OF THE RESPIRATORY APPARATUS. 1 39 

by great quantities of micro-organisms, among which streptococci and 
staphylococci are never missing. 

A rare but very significant constituent of purulent pleuritic exuda- 
tions, also of peripleural abscesses, is the actinomyccs} However, the 
granules which this fungus forms do not pass through the cannula of 
the ordinary hypodermic syringe unless they are very small. Granules 
of considerable size require the use of the larger syringe already men- 
tioned or a thick trocar. Therefore, when there is a suspicion of actino- 
myces reliance cannot be placed upon a fine syringe, which may aspirate 
pus without organisms or not aspirate anything at all. 

HcmorrJiagic cxitdation makes the existence of tubercle or carcinoma 
of the pleura probable. If the exudation \^ feculent, there is some con- 
nection with the intestine. But sometimes there is no disease of the 
pleura at all, but a diaphragmatic peritonitis'^ which simulates a pleu- 
ritis. 

Exploratory puncture, finally, must always be made — 

3. Before operative procedure when pleurisy has been diagnosed, 
even if the diagnosis seems to be perfectly certain. 

From what has been said it is clear that we operate by preference, 
but by no means exclusively, upon the lower parts of the thorax. Of 
course we must avoid the region of the heart, and when there is a sus- 
picion of aneurysm explorative puncture must be omitted ; otherwise 
there is no need of anxiety. When the exploratory puncture is made 
with the observance of every possible precaution it is not a dangerous 
procedure. The puncture is made quickly, in an intercostal space, as 
far as the needle will reach ; if nothing is obtained, the needle is slightly 
withdrawn and suction again made. We may sometimes puncture at 
several points in succession. 

2. Chemical Examination of Aspirated Fluid. 

The greater quantities of fluid which are obtained when aspiration is 
done from therapeutic reasons may be used for chemical examination. 
This is chiefly the determination of the percentage of albumin, which 
has hitherto been made for diagnostic purposes in cases where the 
question was one of differential diagnosis between serous exudations 
and transudations. In the former the average amount of albumin is 4 
to 6 per cent., in the latter about 2 per cent. But, on the one hand, in 
severe hydremia inflammatory exudations may be poorer in albumin, 
while, on the other hand, transudations may contain even as much as 3 
per cent, of albumin (Citron). Therefore the percentage of albumin 
has very httle diagnostic value. Even later examinations and experi- 
ments have not changed this observation. 

In order to simplify the determination of albumin, Reuss has given 
a formula for the direct approximate determination of albumin from the 
specific gravity. The formula is as follows : 

A = f (S. G.— 1000)— 2.80. 
A = albumin in percentage ; S. G. = specific gravity at 1 5° Celsius. 

This formula has the fault that the specific gravity does not depend 
^ See below. ^ See this. 



140 SPECIAL DIAGNOSIS. 

upon the percentage of albumin alone, but also on the other dissolved 
constituents of the fluid. Moritz estimates the average error which is 
caused by that to be only ±0.157. Contrary to him, Citron has found 
the formula to be unreliable in a much higher degree. We ourselves 
had the same experience years ago, and therefore cannot recommend 
the calculation by Reuss's formula. Runeberg has somewhat changed 
the formula, but in no essential way. 

For differentiating between chylous and chyliform extravasations 
chemical examination cannot be omitted. The presence of distinctly 
demonstrable quantities of sugar indicates a chylous extravasation 
— i. e. a communication between the pleural cavity and the ductus 
thoracicus. 

METHODS OF MEASURING AND STETHOGRAPHY. 

Measuring the Thorax. — A single measurement serves to de- 
termine the size of the chest, and to secure an approximate point 
of departure for determining its relation to the development of the 
rest of the body ; but it does not furnish knowledge of diseases 
any better than, with sufficient practice, is given by inspection and 
palpation. 

On the other hand, it has a very great value in connection with 
tracing the cross-section of the chest upon paper if it is employed to 
determine the changes which the chest undergoes in the course of a 
certain disease. 

We measure the diameter of the thorax with the caliper-compasses, 
and it is best to take the broad diameter at the highest point of the 
axilla, the deep or sterno-vertebral diameter on the level with the 
nipple and the insertion of the second rib. In tracing a cross-section 
of the thorax upon paper we must, of course, make the transverse and 
antero-posterior diameters at the same level (whether at the nipples or 
lower down). The circumference of the breast is generally measured 
at the level of the nipple, but sometimes over the highest points of the 
axillae and at the lower end of the corpus sterni. The length of the 
chest may be ascertained by measuring in the mammillary line from 
the clavicle to the border of the ribs. The linea costo-articularis is very 
useful for determining any change in the length.^ 

The delineation of the form of a cross-section of the chest is made 
in the following manner : The opposite diameters at a given point are 
measured and are marked upon a sheet of paper. Next a lead hoop 
or wire is accurately fitted first to one and then the other side of 
the chest at that level, carefully removed and traced upon the paper. 
Instead of the leaden hoop (which is entirely satisfactory), we may 
employ Woillez's cyrtometer, which is a chain with links that move 
stiffly. 

Frequent measurements of the diameters and circumferences, as 
well as tracing the cross-section in the course of disease, may give not 
unimportant results : in determining an increase or diminution of the 
quantity of pleural exudate or of the progress toward recovery by 
the amount of shrinking ; in retraction of the lungs ; but especially in 

^ See under Spleen. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 141 

all kinds of tumors of the chest-cavity. Thus, where aneurysm is sus- 
pected or a mediastinal tumor, the slightest increase in the antero- 
posterior diameter or of the circumference of the chest is of great 
significance. 

In view of what has been said, the statement of the exact measure 
is impossible. It is only important to know that the right side of the 
chest, in people who are right-handed, measures about i to ij- cm. 
more than the left ; also, that the circumference of the chest at the 
level of the nipples in healthy persons is increased in inspiration about 
5 to 7 cm. 

Spirometry, Pneumatometry, and Stethography. — The value 
of these methods of examination for diagnosis is very limited. The 
latter two could even be omitted if they did not sometimes find appli- 
cation in judging of the course of certain diseases. 

Spirometry is employed to ascertain the vital capacity of the lungs 
— that is, the quantity of air which, after deepest inspiration, can be 
given off by the deepest expiration. This is done by means of a 
Hutchinson's spirometer, which is constructed on the principle of a 
gasometer. The quantity of air varies in such a degree not only with 
age, sex, weight, and physical vigor, but also with undefinable indi- 
vidual circumstances, and to such an extent that ascertaining it but 
once has very slight diagnostic value. The relations of the size of the 
body to the vital capacity of the lungs are relatively the most constant. 
Von Ziemssen found that in men, if to each cm. of stature there was 
less than 20 c.cm. of vital capacity (or, in the case of women,. less than 
17 c.cm.), there was either probably a considerable disturbance in the 
organs of respiration (phthisis, emphysema, adhesive pleuritis, bronchitis) 
or it already definitely existed. On the other hand, where the relation 
was as I : 25 (or i : 22) this was improbable. The vital capacity is of 
more importance for supplementing other methods of examination in the 
course of observation of a patient, for the reason that it changes with 
the recovery from, or exacerbation of, the given disease. It is to be 
observed that there seems to be an increase in the vital capacity of 
every patient in consequence of increased practice. Spirometry does 
not here have an independent value. 

Pneumatometry is the determination of the pressure of the respir- 
atory air during inspiration and expiration. It is determined by means 
of the pneumatometer of Waldenburg, improved by Biedert and Eich- 
horst, a modified mercurial manometer. We find that in health the 
expiratory pressure is always greater than the inspiratory, but the 
absolute results vary still more than those obtained by spirometry. 
The diminution of the expiratory pressure in emphysema is important, 
and furnishes a certain conclusion as to the severity of the disease, as 
well as of improvement or extension. Diminished inspiratory pressure 
in stenosis of the air-passages, in phthisis, and in exudative pleuritis has 
no diagnostic meaning. 

Stethography is the graphic delineation of the respiratory motions of 
the chest and of the diaphragm. Different forms of apparatus have 
been constructed to represent graphically thoracic and diaphragmatic 
respiration — among others Riegel's double stethograph, Marey's pneu- 
mograph. Knoll's rubber bottle for epigastric respiration. But as such 



142 SPECIAL DIAGNOSIS. 

apparatuses are not necessary for clinical diagnosis, we omit any 
description of them. 

COUGH AND EXPECTORATION. 

Cough is caused in the following way : By the closure of the glottis 
after a deep inspiration has been taken, the pressure in the thorax by 
means of the auxiliary muscles of expiration is increased, and then 
suddenly the glottis is opened; there results an audible outrush of air, 
which in turn brings with it the substances forming the expectoration 
(which substances cause rales). 

The ability to cough is lost not only when the crico-arytenoidei 
laterales muscles in the larynx, but also the respiratory muscles, are 
paralyzed (bulbar paralysis). Pain, also, may cause suppression of 
cough. 

Cough may be spontaneous or reflex. Reflexive cough-irritation 
may arise from all parts of the mucous membrane of the larynx, 
trachea, and bronchial tubes, as well as from inflamed pleura (" pleural 
cough " no doubt occurring not infrequently). The trachea is espe- 
cially irritable, and particularly the region of the inter-arytenoidean 
space, likewise the bifurcation ; inflamed mucous membrane is more 
irritable than normal. There is never any irritative cough from the 
lung-tissue. 

Cough may also arise reflexively from the stomach and sexual 
organs of women. Here belongs the dry, short, and slight cough of 
many women at the approach of menstruation, as well as the cough of 
hysterical subjects. 

The cough which is caused by disease of the respiratory organs at 
the points above mentioned is either caused by accumulation of secre- 
tion, or more seldom by foreign bodies in the air-passages, or by 
inflammatory processes, by tumors, irritation from pressure, which may 
be in the air-passages or the pleura. In the latter case the cough is of 
course dry ; but if due to increased secretion, the peculiar accessory 
sound varies with its character, whether it be more moist, more fluid, 
or more coherent. 

Cough is thus a most important sign of disease. Moreover, in spite 
of the existence of irritation, a patient whose mind is markedly ob- 
tunded (as, for example, in typhus abdominahs [typhoid fever], in dis- 
ease of the brain, in carbonic-acid poisoning, in the death-agony, etc.) 
may not have any cough ; hence, in these cases there is often consider- 
able mucous rattling in the trachea, without any expectoration. The 
sudden stopping of cough and expectoration in consequence of uncon- 
sciousness, often accompanied with weakness, is therefore, in many dis- 
eases of the lungs, as in pneumonia, a bad sign ; in phthisis, also, it 
sometimes denotes approaching death. It has already been mentioned 
that cough may disappear as a result of paralysis of the muscles con- 
cerned in coughing. 

We can draw no positive diagnostic conclusion from the frequency 
of the cough. Regarding the time of day when it is most apt to occur, 
frequently in phthisis, and also in chronic bronchitis, this regularly 
occurs soon after waking. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 1 43 

Dry cough is generally weak. The ominous dry cough of con- 
sumptives, which probably not infrequently originates in irritation of 
the pleura, is well known, and also the dry pleural cough in commen- 
cing pneumonia, which is suppressed on account of the pain in the 
chest. In a most striking manner this latter cough can also often be 
observed in aspirating the thoracic cavity. But dry cough, as has been 
mentioned above, is occasionally also a reflexion from abdominal 
organs, and, finally, it is sometimes simply a bad habit. 

There is a cougJi with tough expectoration, difficult to be dislodged, 
generally brought up after a long series of labored efforts ; at the end 
there usually is hawking ; the patient often pauses to rest, and then 
continues to cough until a final hawking and expectoration, as in 
emphysema with tough bronchitis and in croupous pneumonia. 

Moist cough with fluid (more purulent) expectoration is easier, 
" looser." Here it is often remarkable what a quantity of sputum is 
thrown off, as from a cavity — sometimes from two efforts at coughing. 
Moreover, with patients who are weak and very miserable often a 
series of efforts are necessary, which efforts then generally end with 
hawking (phthisis in extremis). 

In whooping-cough the cough occurs in pronounced paroxysms. 
Here the inspiration is noisy, because it must be taken as quickly as 
possible, and also because the glottis is narrowed by swollen mucous 
membrane. In consequence of the prolonged effort at coughing, of 
the constantly increasing intrathoracic pressure, and the diminished 
breathing, which causes a disturbance of the interchange of gases and 
blood-stasis, there is cyanosis ; here, as otherwise in long-continued 
labored efforts at coughing, especially in phthisis, very frequently 
they finally end in vomiting. Severe attacks of coughing, moreover, 
result from swallowing the wrong way, as in paralysis of the throat 
from various causes. Unconscious patients often swallow the wrong 
way without any cough. 

The tone of the cojcgh, like the voice, may be unnaturally deep and 
rough in ulceration of the larynx ; in stenosis of the larynx it is either 
a short stenosis sound or rough and bellowing (the latter with children 
with diphtheria or false croup) ; in continued aphonia the cough is 
sometimes toneless, sometimes remarkably rough and sharp. 

Hawking only brings up masses lodged in the pharynx, larynx, or 
the upper part of the trachea ; but it must not be understood that 
what is thus brought up is formed at these locations : it may be 
brought to the lower part of the larynx by previous cough or by the 
motion of the ciliated epithelium of the trachea. 

Expectoration, Sputum. 

By the term expectoration is understood all those substances col- 
lectively that are brought up from the air-passages by coughing and 
hawking. According to the existing disease, they are formed from the 
secretions of the laryngeal, tracheal, and bronchial mucous membrane, 
from the contents of the alveoli of the lungs, and, lastly, from the con- 
tents of pathological cavities of the lungs or from the lung-tissue. In 
rare cases purulent exudations from the pleural cavities, from rupture 



144 SPECIAL DIAGNOSIS. 

of the pleura, may reach the air-passages and appear as sputum ; still 
more rarely, by communication of the esophagus or rupture of an 
aneurysm, particles of food or blood may pass this way. The secretion 
of the mucous membrane or of the glands of the throat, of the mouth, 
of the nose, and also other substances from these locations (as blood, 
micro-organisms, particles of food), mingled in various proportions with 
the expectoration, may give rise to error. Expectoration may be 
entirely wanting, even when the material for expectoration may be 
present in the air-passages in considerable quantity, when there is 
absence of cough, or when the cough is feeble ; ^ finally, it may some- 
times happen in all diseases of the respiratory organs that there is 
either no cough at all or only a dry cough. The blood evacuated 
from the stomach by vomiting may give occasion for swallowing, may 
then be expelled by coughing, and may thus be confounded with pul- 
monary hemorrhage ; but, on the other hand, in hemorrhage of the 
lungs a part of the blood — sometimes a considerable quantity — may 
be swallowed and may give rise to symptoms of hematemesis. 

When possible, it is best to collect the expectoration in a trans- 
parent glass vessel (as a matter of fact, we may readily understand that 
we shall generally have to employ a non-transparent receptacle). As 
much as possible mixture with other substances, as vomited matters, 
is to be avoided. A white porcelain plate, with one-half of its surface 
blackened with asphalt, enables one to scrutinize more exactly the 
expectoration. The expectoration upon both halves of the plate is to 
be examined, and, in order to separate it or to remove a portion for 
microscopical examination, we employ a pair of microscopic needles. 

I. General Characteristics of the Expectoration. — We must 
take into consideration the quantity, reaction, consistence, or form (to 
which latter also belongs the quantity of air mingled with it and its 
arrangement in layers), its color and transparency, and, finally, its odor. 

The quantity of expectoration changes with the amount of material 
which is in a condition to be thrown off, and this differs very much 
with different diseases, also with the strength of the cough. We have 
already referred several times to the influences that determine this. In 
general, patients with certain forms of bronchitis (broncho-blennorrhea) 
and with cavities, especially those with broncliiectasis, have the most 
abundant expectoration — a maximal amount of one or two liters a 
day. Sudden marked increase of expectoration occurs with the rup- 
ture of empyema into the lungs. 

When not much contaminated with vomited matter the reaction of 
the expectoratioii is always alkaline. 

From the above-mentioned general peculiarities {consiste7ice , forrn^. 
color, except only the odor^ we may recognize, according to its chief 
constituents, in which class the expectoration belongs. Accordingly, 
we distinguish — mucous sputum, muco-purulent sputum, purulent 
sputum, serous sputum, bloody sputum. 

Mucous Sputum. — This is either quite glassy and transparent or 
whitish-gray, generally with some consistence and tough ; if more 
fluid, then it consists chiefly of saliva. It occurs in the first stage of 
acute broncliitis from the very slight — what may be called the physio- 

^ See p. 142. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 1 45 

logical — secretion of mucus in the trachea. Very often its source is 
higher up in the pharynx. 

Muco-purulent Sputum. — This consists of a mixture of mucus and 
pus in varying proportions. The latter is recognized by its yellowish 
or yellowish-green color and its want of transparency. It may be dis- 
tributed through the mucus in small particles or strings, or it may 
form larger flocks or balls held together by mucus ; the latter, placed 
in water, are bullet-shaped ; spread out upon the bottom of an empty 
glass, they sometimes flatten out in circular form (coin-shaped sputa in 
case of cavities, but sometimes also in ordinary purulent bronchitis, as 
in measles); finally, in the scanty spongy mucus with slight consist- 
ence, the pus of the separate sputa may run together (" confluent 
sputa "). If the sputum contains many air-bubbles, these cause the 
separate lumps and balls to float in the watery part of the sputum 
(serous fluid or very watery mucus or saliva). Mucus in three layers 
consists of an upper layer of masses and balls, which the air-bubbles 
cause to swim, and from which hang down into the second layer, 
slimy, purulent strings consisting of watery mucus and serum ; on the 
bottom is a layer entirely confluent, like a deposit of decomposed pus 
(fetid bronchitis, gangrene of the lung). 

Purulent sputum consists of almost pure pus, whose source is 
either an abscess of the lung which has given way or an empyema. 
Sometimes almost pure pus may be coughed up when there is a sud- 
den very considerable discharge from a cavity. As it traverses the 
air-passages, there is always some mucus mixed with it. 

Serous sputum is a special pecuharity of the sputum of edema of 
the lungs. It is very fluid, although, on account of the admixture of 
mucus, not so much so as blood-serum, being mixed with mucus. It 
consists of blood-serum, and hence contains albumin ; for this reason it 
retains air-vesicles for a long time, as do all fluids containing much 
albumin; it is markedly frothy. It is either a quite light gray and 
transparent, or, as is frequently the case, like beef-juice, owing to a 
slight admixture with blood; when containing much blood it is the 
color of prune-juice (edema of the lungs with pneumonia). 

Bloody Sputum. — All of the varieties of sputum previously men- 
tioned may be mixed with blood. SHght mixture of blood is seen in 
the expectoration of tough mucus as bloody streaks. These are gen- 
erally mixed from the upper air-passages, often from the throat or nose, 
yet sometimes they arise from the lungs or the smallest bronchial 
tubes, as in pneumonia. A small quantity of blood, with partial escape 
of coloring matter of the blood, intimately mixed with tough, glassy 
mucus, colors the sputum uniformly bright red with a greenish tinge, 
or, by transformation of the coloring matter of the blood, makes it 
yellowish-red, rusty, even greenish (all of these with pncnnwnia). In 
muco-purulent sputum blood appears either in streaks or as little spots, 
as in phthisis, or intimately mixed : the pus is then reddish-yellow, 
brownish-yellow, or more markedly reddened, as it more partic- 
ularly occurs in bronchiectasis and phthisical cavities, but also some- 
times in atypical lobar and broncho-pneumonias. Brownish bloody 
sputum in phthisical subjects may always be referred to a compli- 
cating broncho-pneumonia. When there is only a small admixture 
10 



146 SPECIAL DIAGNOSIS. 

of blood serous sputum, as was mentioned above, is the color of 
beef-juice. 

If there is considerable Jiemorrhage with the expectoration, it is 
markedly colored with blood ; sometimes there may apparently be no 
sputum, but fluid blood may be expectorated in a liquid state, coag- 
ulating afterward, This is described as hemoptysis. When a pul- 
monary hemorrhage is quickly coughed up, the blood is bright red 
and frothy from being mixed with the sputum, but sometimes it gushes 
out in such quantity that there is no cough. It is distinguished from 
blood that comes from the stomach, in that the latter, from longer 
stagnation and from the effect of the secretion of the stomach, generally 
is darker, quite brown, like coffee-grounds ; besides which it is often 
mixed with food and Jias an acid reaction. Yet the blood from the 
lungs, though only when there is considerable quantity, may be also 
dark, even black-red, if it has stagnated in the lungs or air-passages : 
thus, a patient who has had an hemoptysis may continue for a whole 
day to throw off markedly bloody sputum, which becomes more and 
more dark in color. 

HenwrrJiage of the lungs occurs very much more frequently with 
tuberculosis than from other causes. In this disease there occur all 
varieties of hemorrhage, from the scarcely visible particles of blood or 
a slight coloring of the purulent discharge from a cavity to the profuse, 
almost immediately fatal hemorrhage. Moreover, in infarction of the 
lungs there may be bloody sputum, or even pure blood may be dis- 
charged. Croupous pneumonia and edema of the Inngs are generally 
accompanied with slight quantities of blood intimately mixed with the 
sputum. 

Sometimes it is perfectly easy to diagnose hemorrhage of the lungs, 
and again it is extremely difficult. Particles and streaks of blood 
occurring in the midst of purulent material are very suspicious. If 
they occur with gray mucus, it is generally quite unimportant, because 
in the latter case they usually come from the pharynx or its neighbor- 
hood ; but when there is considerable hemorrhage there may be doubt 
as to whether the blood comes from the stomach or lungs if the blood 
is expectorated very rapidly, and so is yet bright red, and if, during the 
act of vomiting, some blood is aspirated and causes cough. On the 
other hand, blood from the lungs may seem to come from the stomach 
if, from stagnation, it is unusually dark or if a part of it is swallowed 
and then vomited. When the patient is unconscious or asleep, blood 
from the nose or throat may be drawn into the air-passages, and then, 
after considerable has accumulated, be coughed up, but more frequently 
it flows into the stomach. In the latter case, by inspection of the 
throat we may sometimes see a streak of blood marking the track upon 
the posterior wall of the pharynx. In all such cases a decision is to be 
reached by the most careful examination of the lungs, stomach, and 
nose. 

A peculiar sputum, like raspberry jelly, is observed in cases of 
tumor of the lungs. 

Sometimes in hysteria there is an expectoration from the pharynx 
or esophagus of a peculiar raspberry red, which may mislead one 
(years ago described by E. Wagner). 



EXAMINATION OF THE RESPIRATORY APPARATUS. 1 47 

Green Expectoration. — When sputum is left to stand, say in a jar, for 
some time, it becomes green. We now know, from the investigations of 
Frick, that this is due to a green-producing bacillus. This change of 
color is without any diagnostic significance. Regarding sputa which 
are green when expectorated compare the next following pages. 

TJie odor of spiitiun is ordinarily stale ; when it is scanty, it is often 
offensive from mixture with the secretions of the mouth, especially 
among the lower classes or when the patient is very sick. Purulent 
sputum from a cavity, if it has been long retained, may be putrid or 
have a peculiar putrid-rancid odor (only with phthisical patients in 
extremis). In cases oi fetid bronchitis^ bronchiectasis, and gaiigrene of 
the Inngs a more marked and very characteristic, sharper and more 
penetrating, quite offensive odor from the muco-purulent sputum 
decomposing in the air-passages is commonly present ; but in the last- 
mentioned disease it may be entirely wanting (^' odorless gangrene''^. 
Offensive odor of sputum may sometimes be caused by decomposition 
of particles of food in the mouth or by offensive plugs in the lacunae of 
the tonsils, and thus one may be entirely deceived. 

A penetrating, aromatic, fruit-like odor of sputum, resembling the 
odor of stewed prunes, has lately been described by Eichhorst. It 
precedes the rupture of an echinococcus into the air-passages and the 
appearance of the membranes in the expectoration. 

2. Foreign Substances in the Sputum which are Visible to 
the Unaided l^ye. — Nowadays the microscopical examination of the 
expectoration with its brilliant, but partial, results, is carried to such 
an extent, and so calls the chief attention to this secretion, that it 
seems necessary to draw attention to the importance of examining it 
with the unaided eye. Carefully conducted, it not infrequently brings 
the physician, in difficult cases, directly to a correct diagnosis, besides 
facilitating the use of the microscope in showing how to find the right 
spots from which to take the particles for closer examination. 

The inhalation of coal-soot (most frequently by those especially 
exposed to it, but also by all dwellers in cities) colors the sputum, in 
streaks or diffusely, blackish-gray. When iron-dust is inhaled, it colors 
the sputum quite black or ochre-yellow and red.^ When the sputum 
is scanty it is more deeply colored than when it is abundant, since in 
the former case the coloring-matter is more concentrated. 

We have already referred to the addition of blood. The presence 
of heinatoidin is sometimes evident to the unaided eye by a yellowish 
or brownish-red color in separate spots ; it occurs in the lungs when 
there is disease of the Jieart, in cases of abscess of the lungs, and in 
empyema?' 

In icterus the bile-pigment is sometimes present in the expectoration ; 
I have often observed that in pneumonia zvith icterus, more particularly, 
it colors the sputum a distinct yellow-green or green.^ 

In abscess of the lung we observe lung-tissue in the shape of larger 
or smaller pieces. These 'Mung sequestra" may sometimes be very 

^ See on this point, also, under Microscopical Examination. 
^ Confirmation by the Microscope, see below. 

' Compare also what has been said above about green coloration of sputum that has 
been standing some time. 



148 



SPECIAL DIAGNOSIS. 



large — 2.5 cm. long (Salkowski of Leyden). Pieces of cartilage from 
the trachea or the bronchial tubes in deep tdceration and the accom- 
panying perichondritis of these organs will sometimes be coughed up. 

Fibrinous tubes, formed in the bronchial tubes as a result of fibrinous 
inflammation there, may form a more or less considerable part of the 
expectoration. We may have a firm cast of an entire dichotomous 




Fig. 35. — Large bronchial coagulum (chronic fibrinous bronchitis) (after Riegel). 

ramification of a large bronchial trunk, even to the finest branches 
(even to the alveolar tubes and the alveoli ?) ; more frequently they 
come from the smaller bronchi, and are only divided two to five times. 
Very often these casts are thrown off while they are fresh, as is evident 
oy their white color; they are also often yellowish-brown, or else 
reddish, from the addition of blood. They are often found as irregular 



EXAMINATION OF THE RESPIRATORY APPARATUS. 



149 



lumps covered with mucus or small flakes, so that the inexperienced 
do not recognize their true character. In order to make them out it is 
necessary to isolate them by shaking them up with water in a test-tube. 

Generally they exist only as casts of the smaller bronchial tubes in 
crotipous pneumonia, and are most abundant shortly before and during 
resolution, as dense large casts in chronic croupous bronchitis, and in 
acute croupous broncJiitis in consequence of laryngeal and tracheal 
croup! 

Complete casts of the trachea, and even of the larynx, are some- 
times thrown off in croup. Casts wholly from the smallest bronchial 
tubes, or, in reality, from the alveolar channels, occur in bronchial 
asthma, and more rarely in croupous pneumonia, as the so-called 
spirals. If they are small, they form in the expectoration (compare 
page 154) diminutive gray transparent or whitish opaque flocks or 
lumps which frequently, on close examination, look like fine hairs 
rolled together. The finest forms of these spirals, the so-called nude 
central threads, are most frequently found in light gray, egg-shaped or 
globular corpuscles scarcely the size of a millet-seed. 

Regarding echinococcus bladders and the exotic Distoma puhno- 
num (Balz) found in the sputum, see under Microscopical Examination, 
page 157. 

Of the crystals occurring in the sputum (which, of course, can only 
be perfectly made out by examination with the microscope), sometimes 
by careful examination with the naked eye two forms may possibly be 
recognized. In the fetid sputum 
in three layers (fetid bronchitis 
and gangrene of the lungs) there 
exist peculiar grayish-yellow, very 
offensive lumps, which may be 
barely visible or may be as large 
or larger than lentils ; these lumps 
enclose fat-crystals.^ These same 
bodies occur as offensive plugs 
from the lacunae of the tonsils, 
although never in so large a quan- 
tity as in the other conditions. 
Hence when they are found in the 
sputum we must always carefully 
examine the tonsils. 

Further, in chronic croupous 
bronchitis and in bronchial asthma 
there are found imbedded in the 
sputum, sometimes adhering to 

the concretions, peculiar small bodies, yellowish kernels, like grains of 
sand, which easily strike the practised eye ; these, generally numerous, 
are the so-called Charcot-Leyden's crystals.^ 

It remains to mention some fungi found in the sputum whose pres- 
ence may be indicated by the macroscopical examination, but this 
examination would be without diagnostic value unless confirmed by 
the microscope. Different kinds of mould, especially Aspergillus 

^ See further, p. 156. '^ See p. 156/ 




Fig. 36. — Bronchial coagulum, natural size, 
with croupous pneumonia. 

Tn this disease the small forms are very frequent, 
the large ones very rare, but frequent with chronic 
fibrinous bronchitis. 



150 SPECIAL DIAGNOSIS. 

fumigatus, are very rarely found, except as a pathological result, and 
generally in phthisical and bronchiectatic cavities, which are noticed as 
gray or greenish little collections ; muguet} as white tufts almost 
always arising from the mouth and throat (hence, these are to be care- 
fully examined) ; only in quite isolated cases they come from the upper 
air-passages. 

The finding of actinoniyces in the expectoration is of greater import- 
ance, but of yet greater rarity. It can be recognized by the naked 
eye by the little kernels of uniform size, shaped Hke millet-seeds, 
greenish-yellow or yellowish-white, sometimes somewhat glassy (I 
have seen them in one case, since then they have been seen several 
times by others) ; of course they are only to be accurately recognized 
by the microscope. 

There is another fungus, occurring in granules much like those of the 
actinomyces, which can scarcely be mistaken for anything else, the so- 
called leptotJirix biiccalis. The granules are smaller, more irregular, and 
more whitish than those of the actinomyces — sometimes Hke little scales, 
sometimes not distinguishable from minute bread-crumbs. Under the 
microscope they consist only of fungus threads, which are arranged 
after the manner of the leptothrix, and give the same reaction.^ Such 
sputa sometimes (not often) on standing gradually become yellowish 
or develop a yellow coating — luxuriated leptothrix, as has been hitherto 
assumed. The granules are particularly found in chronic bronchitis 
and bronchiectasis. The finding of large masses of tubercle bacilli is 
sometimes made easier by the presence of yellowish, generally flat 
lumps — " lentils " — in the sputum from cavities, which, besides, usually 
contains many elastic fibers ^ and, also, although much more rare, if 
there are small white (barely visible) scales, very much like those of 
which the artificial pure culture of the bacillus tuberculosis consists. Both 
elements, especially the latter, usually contain or consist of masses of 
baciUi. It is very easy to be deceived by the admixture of food-particles 
in the sputum. Chiefly is this the case from minute bread-crumbs and 
small white lumps of coagulated milk (which not infrequently contain 
fat-crystals). 

3. Microscopical Examination of the Sputum. — Small par- 
ticles are placed under a glass cover, which is to be only moderately 
pressed. It is to be examined with a No. 7 or 8 Hartnack, or DD or 
F Zeiss. 

In all mucous and muco-purulent sputum there 2.xq threads of mucus 
and mucous corpuscles; the former are more sharply defined the 
tougher the mucus is. In pneumonia and asthma they are often spiral, 
and in these diseases they pass by imperceptible gradations over into 
the finest and most delicate fibrinous formations."* 

White blood-corpuscles are found in all expectoration, but in much 
greater numbers in the purulent parts. They are generally of various 
sizes, granular, not infrequently filled with drops of fat and myelin or 
contain particles of soot ; or also, in rare cases, contain minute lumps of 
hematoidin.^ Regarding the occurrence of greater numbers of eosino- 
phile cells in the sputum of asthma, see page 157. 

^ See this. ^ See below, p. 158, ^ See below, p. 152. 

* See Spirals, p. 154. ^ ggg p_ 155^; 



EXAMINATION OF THE RESPIRATORY APPARATUS. 



151 




Fig. 37. — Epithelium from the sputum : a, 
flat epithehum from the mouth ; b, the so-called 
alveolar epithelium, containing little drops of fat 
and myelin ; d, a red blood-corpuscle ; e, mucus- 
cells ; f, oscillating cells. 



Red blood-corpuscles are found in the different kinds of bloody 
sputum, generally with the form well preserved, but often paler, even 
as rings ; when the sputum has been retained for a long time they are 
granular. 

Epithelium. — Flat epithelial cells from the mouth are a common 
ingredient of the sputum. They are easily recognized by their size 
and thinness, the latter manifests itself by numerous cracks and folds. 
Flat epithelium, which probably comes from the esophagus, occurs in 
large clusters in the so-called bloody sputum of hysteria. 

Changed cylindrical epithelium of the air-passages in the form of 
mucous and goblet cells are ob- 
served in all cases of catarrh of 
the trachea or of the bronchi, 
and sometimes in large numbers. 
On the other hand, it is rare to 
find these epithelial cells in their 
original condition, with homo- 
geneous protoplasm, with blad- 
der-like nucleus, covered with 
cilia ; and still more rare to 
obtain the motion of the cilia or 
to find it responsive to heat. The 
possible origin of these cells in 
the nose is not to be overlooked. 
They have diagnostic value. 

The so-called alveolar epithe- 
lium (see Fig. 37) was formerly considered an important constituent of 
the sputum. But it is neither possible to affirm its source nor to give 
its diagnostic value. There are elliptic or round, not infrequently 
somewhat flattened, cells with an often indistinguishable nucleus (made 
visible by the addition of acetic acid), larger than the ordinary white 
blood-corpuscle. The protoplasm is fine or coarsely granular, some- 
times filled with drops of fat or myelin (Virchow) ; also we may see 
complete fatty degeneration with formation of large fat- and myelin- 
drops. These cells contain particles of coal- or iron-dust (the latter 
made dark green by sulphide of ammonium, blue by yellow prussiate 
of potash and muriatic acid). This alveolar epithelium occurs in bron- 
chitis and all kinds of acute and chronic pneumonia, hence does not 
have any diagnostic value. Its epithelial character is not at all constant. 
I think it quite probable that it is mostly or altogether made up of 
white blood-corpuscles, enlarged by metamorphosis of their proto- 
plasm, and partly by absorption of small particles. In part, also, this 
may come from the deeper layer of the bronchial epithelium (Panizza, 
Fischl, Senator). 

The so-called heart-disease cells are cells which show great con- 
formity with those last mentioned in shape, size, form, and visibility 
of their nucleus, but they are partly filled with very fine, partly with 
larger, yellow or brownish Httle nucleoli. This nucleolus consists of 
hemosiderin, an iron-containing derivative of hemoglobin (F. A. Hoff- 
mann). These cells are no doubt principally leukocytes, a small num- 
ber of them also being alveolar epithelia. If they are present in con- 



1^2 



SPECIAL DIAGNOSIS. 



siderable quantity, they give a yellowish-brown tint to the sputum or 
to parts of it. These cells are almost pathognomonic of conditions of 
the lungs associated with he ai't- disease — i. e. brown induration of the 




Fig. 38. — Elastic fibers, from a mass in the sputum fi-om a phthisical cavity, without change. 

Zeiss, F. Oc. 3. 



lungs, which is caused by long-continued defective flow of blood in the 
lesser circulation ; disease of the mitral valve, myocarditis, adhesive 
pericarditis. Similar cells are also seen in small numbers in cases 
where blood appears in the sputum, 
particularly where there is old bleed- 
ing [extravasations], as infarction of 
the lungs, shghtly bleeding bronchi- 
ectasis, also pneumonia. 

Elastic fibers are an important 
constituent of sputum, since they in- 
fallibly show the destruction of lung- 
tissue (less frequently of the tissue of 
the bronchi), but still more because 
they indicate a severe disease of the 
lungs often before there are physical 
signs of it. They occur in tubcrcidosis, 
gangreiie, abscess of the lungs. They 
generally have a double outline ; now 
and then there are branching fibers 
which have a serpentine course or 
large irregular curve. They gener- 
ally lie in bundles, and often show 
the structure of the lung-vesicles. 
(Compare Figs. 38 and 39.) 

They always exist in clusters and with a remarkably alveolar 
arrangement in the shreds of lung-tissue in abscess of the lungs and 




Fig. 39. — Elastic fibers, sedimented after 
treatment of sputum with alkali. 



EXAMIiVATWiV OF THE RESPIRATORY AFFAjRATUS. I 53 

when there is suppurating gangrene; further, almost always in the 
so-called "lintels" of tubercular sputum. When elastic threads occur 
singly, which may be in all the conditions named, it is very difficult 
to say which is their special cause. Then, also, it is not easy to dis- 
tinguish them from fat-crystals,^ and farther from elastic fibers in food. 
Besides, since the discovery of the bacillus tuberculosis their impor- 
tance for the early diagnosis of phthisis has disappeared ; but for deter- 
mining whether we have a more or less destructive form of phthisis 
they are as valuable as ever. 

Method of Examination. — A suspicious particle of sputum is placed 
on the sHde, then there is added either pure water or a drop or two of 
a 10 per cent, solution of potassium hydrate, and the cover-glass is put 
on. In the solution of potassium hydrate all particles of tissue swell 
to a uniform jelly, except the elastic fibers, which stand out distinctly. 

To obtain elastic fibers when they are not present in quantity, a 
portion of sputum is boiled with an equal quantity of an 8 to 10 per 




Fig. 40. — Curschmann's spirals, natural size (after Curschmann). 

cent, solution of potassium hydrate ; then the jelly-like mass is to be 
diluted with water and allowed to stand for twenty-four hours. The 
elastic fibers, as distinct organic substances, settle to the bottom, but 
are often much swollen and not readily distinguished from fibers of the 
food. The elastic fibers may also be separated in a few minutes by the 
centrifuge. 

In individual cases o{ gangrene of the lungs, but by no means in all, 
elastic fibers may be wanting ; possibly they may be destroyed by the 
action of a ferment (Traube) [see page 164]. Moreover, simple gan- 
grene of the lungs is rare ; we generally have a suppurating gangrene, 
and this can hardly fail to furnish the shreds of lung-tissue previously 
described. 

^ See under, p. 156. 



154 



SPECIAL DIAGNOSIS. 



Spirals (Leyden, Curschmann, and others). — By this name we 
understand spiral forms which are found almost exclusively in the 
coherent mucous sputum of bronchial asthma, but are also found in 
other sputa having the same ropy, mucous consistence. 



Fig. 41. 



Fig. 42. 



Fig. 43. 








K.;mj^? 



Figs. 41-43. — Curschmann's spirals : a, central fiber (after Curschmann). 



With a little practice the larger of these spirals can be recognized 
by the naked eye. If placed under a cover-glass and slight pressure is 
made, so as to spread the sputum out thin, even without a magnifier 
spiral fibers can be seen, and not infrequently in their interior a shining 
stripe, which generally is wavy. It is easy to imagine that this stripe is 
a long-stretched spiral. If slightly magnified by a good magnifying- 
glass or a Zeiss A A with ocular No. 2, it can be distinctly seen that in its 
outer parts the spiral is formed of loose, corkscrew-like fibers, while the 
shining, bluish-shimmering stripe in the interior appears more homo- 
geneous. But if still more strongly magnified, we recognize on the 
stripe also a few very fine spiral threads. The loosely-wound exterior 
part of the spiral has lately been frequently called the mantle spiral, 





Tig 44 — \ude central thrtids in asthma 
sputum mag 240X 



Fig. 45. — Nude central threads in asthma 
sputum; mag. 585X. 



while the central stripe, as proposed by Curschmann, is called the 
central fiber. 

In the mantle part of the spirals cells are always present : very fre- 
quently numerous round-cells containing one nucleus, with eosinophi- 



EXAMINATION OF THE RESPIRATORY APPARATUS. I 55 

lous granulations, sometimes of considerable size. Also asthma-crystals 
may be found here, and occasionally cells containing hemosiderin. 

Often the spirals, particularly the larger ones, are without the cen- 
tral thread. On the other hand, if strongly magnified, the central 
threads are found in the midst of small balls of sputum without mantle 
spirals — isolated or nude central threads. The finest glassy little flocks 
of asthma-sputum, described above,^ very often contain a good many 
spirals, and some of them are quite long, although very fine (Figs. 44 
and 45). By the Weigert fibrin stain, which also stains the mucin, 
Schmidt has demonstrated them in hardened sputum. With some 
practice they are easily found without staining. 

According to the color-reactions, there can be scarcely any doubt 
that the central threads consist of mucin. They are certainly not the 
artificial expression of a cavity, as was formerly frequently supposed. 
It may further be supposed that the central threads do not signify 
anything more than that the innermost part of the spiral has been 
consolidated and afterward stretched. 

These formations are found in bronchial asthma to such a prevailing 
degree that they are of important significance for the diagnosis of this 
disease. They are usually most abundant in the expectoration which 
is thrown off toward the end of the attack. Possibly also they partici- 
pate in producing the attack. They are also found in small numbers 
in quite different states, especially in chronic, obstinate bronchitis and 
emphysematous bronchitis, in bronchitis accompanying heart-disease, 
in croupous pneumonia, and here, usually simultaneously with coag- 
ulations, also in very chronic pulmonary tuberculosis, and finally in 
hemorrhagic infarction. 

The conditions in which they appear all have this in common : a 
coherent mucous sputum and a certain degree of dyspnea. It is re- 
markable that where there are the most ropy sputum and the severest 
dyspnea, as in bronchial asthma, the spirals are most numerous and 
most perfect. 

Gerlach by twisting particles of ropy mucus has produced not only 
spirals, but also central thread-like formations ; but it has not yet been 
proved that these artificial central threads have the same strong affinity 
for certain anilin colors as the natural ones have. The suggestion 
naturally arises that in the bronchi also these forms originate by the 
twisting of the particles of sputum. This seems to be self-evident at 
once if we consider the appearance of the spirals. But how and where 
this twisting takes place no one has yet shown. Schmidt found spirals 
with central threads in the upper lobes of a diseased asthmatic patient 
in the majority of the bronchi that had a diameter of one to three milli- 
meters. This, thus far, is the only fact which directly bears upon the 
question ; everything else bearing upon the place and manner of forma- 
tion of the spirals is merely conjecture. 

Starch-corpiisclcs. — These are often found in hemorrhage of the hings 
(Friedreich), and in gangrejie (von Jaksch), but are as yet without 
significance. 

Crystals. — Crystals of heniatoidin are brownish-yellow if pure, of a 
shining color, rhombic plates or fine needles, and these single, or two 

^ See p. 149. 



156 



SPECIAL DIAGNOSIS. 



or three crossed, or in tufts. The crystalHne formation may also occur 
as grains and lumps ; not infrequently in the center is a white blood- 
corpuscle, and it may be that the needles are arranged with their points 



7^ 



i 











Fig. 47. — Needles of fatty acids 
(after Striimpell). 



standing out from the cells. They indicate that blood has been long 
retained : in gangrene with formation of abscess ; in the pus of empyema 
which has perforated a long time before, as in one case that came under 
my observation of a slow hemorrhage into the lungs from a thoracic 
aortic aneurysm. Sometimes there are spots macroscopically visible 
when there is hematoidin in the sputum.^ 

Crystals of fatty acid (margaric-acid crystals, see Fig. 47). They 
are long, thin, slender needles, sHghtly or very markedly bent, which 

are found singly, in large bundles or 
nodules, or quite irregularly arranged. 
They are generally distinguished 
from elastic fibers by the uniformity 
of their curving. When a portion of 
sputum is dried in the air without 
heat, they are completely dissolved 
upon the addition of ether, while the 
elastic fibers under the same circum- 
stances are not changed. They occur 
generally in masses in gangrene of the 
lungs and fetid bronchitis, and espe- 
cially in the lumps or plugs previously 
mentioned ; ^ they are also found in the plugs which are formed in 
inflamed tonsils ;^ finally, they may occur singly in any muco-purulent 
sputum, especially after standing in a warm place for some time. 

C holesterin Crystals. — These are thin rhombic plates with the 
corners cut out, which become green and then red when treated with 
dilute sulphuric acid and tincture of iodin. They are sometimes found 
in old perforating pleural pus, also in tuberculosis. 

Charcot- Ley den's Crystals. — These are slight, somewhat blue, shin- 
ing, elongated octahedrals of great variety of size, sometimes visible. 




Fig. 48. — Crystals of cholesterin 
Striimpell). 



* See p. 146. 



See p. 149. 



See p. 149. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 



157 



with a simple microscope, often only to be seen with a No. 8 Hartnack. 
They seem to be identical with the crystals found in the blood and 
marrow in leukemia^ also sometimes occurring in the feces.-^ They 
probably consist of a mucous substance (Salkowski). 

As a sign of bronchial asthma they are of great diagnostic import- 
ance ; ^ they then occur most abundantly during and after the attacks 
(Leyden). They are less frequently found in acute bronchitis , chronic 
croupous bronchitis, and tuberculosis. 




Fig. 49. — Charcot-Leyden's asthma-crystals (after Riegel). 

In the expectoration of asthma the points where these asthma- 
crystals are found can often be easily recognized with the naked eye 
as dry crumbs.^ They are often mixed with pecuhar, fine, granulated 
round-cells which look as if filled with dust ; at the same time with 
these are found spindle-formed figures with a slight ghstening — a 
transition stage to Charcot's crystals (?). F. Mliller and Gollasch 
lately found that the granulated cells are eosinophilous.* The spindle- 
shaped formations also contain eosinophilous granules. These crystals 
and eoscophilous forms are found especially numerous upon and in the 
" spirals." 

In isolated cases there are found in the sputum tyrosin {fetid bron- 
chitis, empyema, according to Leyden), oxalate of lime {diabetes, Fiir- 
bringer ; asthma, Ungar), and triple phosphate^ 

Animal Parasites. — We may have whole echinococcus bladders or 
their fragments (recognized upon cross-section by the remarkably 
uniform streaking (see Fig. 51), and also the hooks of the scolices 
(Fig. 50) in the sputum in case one of these parasites enters the 
bronchial tubes by rupture from the lungs or liver. (They are slightly 
magnified.) 



^ See under Stools. 2 ggg Spirals, p. 154. 

'* Compare the Blood in Leukemia. 

5 See chapter on Urine, for illustrations of these substances. 



See p. 149. 



158 



SPECIAL DIAGNOSIS. 



The Distoma pulmonale (Balz), which causes hemorrhage without 
any other manifestation, declares itself by its eggs in the sputum (to 
be seen by the simple microscope). It is found in foreign countries, 
especially Japan. 




f 



-% 



Fig. 50. — Echinococcus (scolices) (hooks, after Heller). 

InfiLSoria {Monas, Cercomonas — Kannenburg) are found in gangrene ; 
they are seemingly without pathological significance. 

Fimgi :^ Leptothrix buccalis, as has already been mentioned, page 
150, is present in the yellow scum arising on sputum that has been 
standing some time, besides the fatty-acid crystals in the bronchial 
plugs in putrid bronchitis, and also occurring separately in gran- 
ules which resemble those of actinomyces. Either it is first mixed 
in the sputum in the mouth or it has entered the air-passages from 
the mouth, but it is present there without any known patholog- 




FiG. 51. — Echinococcus membrane, cross-section enlarged. 



ical significance. Specific reaction: With iodin and potass, iod. it 
is stained blue-red. [For formula, see page 163.] Without this 
reaction it may be confounded With elastic threads, even with fatty 
acids.^ 

^ For the macroscopical evidence of the presence of some of them, see page 149/. 
2 See the chapter on the Digestive Apparatus and Microscopical Examination of the Con- 
tents of the Mouth-cavity. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 159 

Sarcina pulmonalis is a fungus formed by division from developing 
endogenous spores (Hauser). While similar, although smaller, it has 
nothing to do with sarcina ventriculi. The recent views upon its frequent 
presence may be somewhat questioned (confounded with Micrococcus 
tetragenus ( ? ), Fliigge). It has no known pathological significance. 

Tubercle Bacillus (Koch). — This generally occurs in the purulent 
parts of the sputum of tuberculosis of the lungs or trachea. Exception- 
ally it may be mixed with the sputum from the throat or nose if a tuber- 
cle breaks up at that point. The bacilli are generally very abundant 
in the so-called " lintels," and in rare cases as small pure cultures in 
the tiny white scabs which were spoken of above, page 150. These split 
fungi are straight or moderately — rarely much — bent, very thin rods 
of somewhat variable length, 2 to almost 4 fj^ — that is, about the diam- 



/ 



_ -^ 

^ "" 



\ 
/ 



>^ 



Fig. 52. — Tubercle bacilli in the sputum, first colored with anilin-fuchsin, and then with 
methylen-blue. Zeiss's homog. immersion jJg- Oc. 4, camera lu4ida drawing ; magnified about 
1000 diam. 

eter of a moderate-sized white blood-corpuscle. They often contain 
spores. On account of their thinness, and because they are without 
motion, they are with difficulty seen in the sputum unless they are 
colored. In order to bring them into view we stain them, and by a 
method which at the same time produces a special reaction, a very 
certain proof that it is the tubercle bacillus and not one of the numerous 
other bacilli. It is to be magnified 600-400, or, for those accustomed 
to examine for it, 300, diameters — that is to say, with a -^-^ oil immer- 
sion lens (with an Abbe condenser), or a Hartnack No. 8 or at least 
No. 7, Zeiss F. 

Microscopical Demonstration of the Tubercle Bacillus. — Only three 

^ [The Greek letter // represents one-thousandth of a millimeter (/^ = o.ooi mm.), and 
is the sign of a micro-millimeter or a microrz.'] 



l6o SPECIAL DIAGNOSIS. 

of the numerous methods of staining are mentioned here, the second of 
which — Ziehl-Neelsen — is the one most in use at the present time. 

I. (Weigert, EhrHch). — With perfectly clean needles we place some 
sputum upon a plate with a black surface, and there spread it out with 
the needles. From this is selected a suitable portion,^ which is placed 
upon a glass cover, and then it is to be broken up with the needles. 
Upon this is now placed another glass cover, and the two are pressed 
firmly together. What is squeezed out upon the edges is to be 
washed away, and then the two glasses are to be carefully separated, 
so that there may remain upon each the thinnest possible layer, equally 
distributed. These are then laid aside to dry. Then 12 drops of anilin 
oil are thoroughly mixed with a small test-tube full of distilled water, 
it being shaken till it is intimately mixed. The mixture is allowed to 
stand for a short time, and then some of it is to be filtered through a 
moistened filter into a watch-glass. From a previously prepared con- 
centrated alcoholic solution of fuchsin there is then to be added suffi- 
cient to make the mixture opaque or to cause a slight metallic shimmer 
to appear upon the surface; about 6 drops are necessary. Good 
fuchsin S. is necessary. 

The glass covers are allowed to dry in the air, and then each is 
passed three times through the flame of a spirit-lamp and laid in the 
coloring solution with the sputum side down. The watch-glass, 
covered over, is allowed to stand for twenty-four hours, or it is slowly 
warmed over the spirit-lamp until a slight deposit of moisture appears 
not only upon the edges, but also upon the middle, and then it is set 
aside for about ten minutes. 

The manipulation is continued by washing the glass cover in water, 
and then for a few seconds dipping it in a mixture of i part of nitric 
acid and 2 of water (without letting go of it with the pincers) until it, 
being again washed in water, continues to show a slight red shimmer. 
Then the preparation may be immediately examined in water: the 
tubercle bacilli are colored an intense red, while all the rest is colored 
a pale reddish tone. It is advisable to stain the glass cover a second 
time with a watery solution of methylen-blue. This is done by placing 
it in this solution for a minute or two after taking it out of the acid 
mixture and thoroughly washing it with water. Then it is again 
washed, when it may be examined. 

Instead of fuchsin and methylen-blue, we may, in exactly the same 
way, employ gentian-violet and Bismarck-brown. The preparations 
are preserved by first drying them in the air, then passing them three 
times through the flame before laying them upon sHdes upon which 
has been placed a drop of xylol-Canada balsam. 

The decolorizing with the nitric-acid solution must not be too pro- 
longed, else the bacilli lose their coloring. With preparations that are 
to be preserved the nitric acid must be very carefully removed by 
repeated washings with water, because the acid destroys the color. 

The alcoholic gentian-violet, as well as the fuchsin solution, retains 
its color very well. Sometimes the Bismarck-brown, and also the 
methylen-blue, must be filtered before using. Besides these, one needs 
for his work a black plate, two quite long microscopical needles which 

^ See above. 



EXAMINATION OF THE RESPIRATORY APPARATUS. l6l 

must be heated red hot each time before using, a pincette with broad 
beak, some watch-glasses, glass slides and covers, and a spirit-lamp. 

II. (Ziehl-Neelsen). — In this method, instead of the anilin-water 
fuchsin, there is employed a mixture of 90 parts of a 5 per cent, solu- 
tion of carbohc acid and 10 parts of concentrated alcoholic solution of 
fuchsin. Staining is also done by warming, and in everything else the 
same as in I. 

III. (Gabett). — A briefer but less certain, and hence less useful, 
method has been recommended by Gabett : A dry preparation which 
has been passed through a flame is placed for two minutes in a solu- 
tion of I part of fuchsin S. in lOO parts of a 5 per cent, solution of 
carbolic acid and 10 parts of absolute alcohol, and then, immediately 
after, for one minute in a solution of 2 parts of methylen-blue to 100 
parts of 25 per cent, sulphuric acid. It is rinsed with water, and then, 
for preservation, is dried and mounted in Canada balsam. The prepa- 
rations, if successful, are very beautiful and permanent; but the dis- 
coloration is difficult to control, because it is carried on in the colored 
solution : sometimes it is too strong, sometimes too weak. It is best 
not to attach any importance to a negative result. 

Note. — For handling the cover-glass it is best to use a Cornet's pincers. With some 
practice the staining solution may simply be dropped on the cover-glass, and then this is 
heated directly over the flame till it steams, but is not allowed to boil. The staining solution 
is added drop by drop on the glass, so as to keep it moist. If by chance there are thick por- 
tions in the preparation which are difficult to decolorize, it may be dipped alternately into a 
30 per cent, solution of acid and into alcohol in order to decolorize the preparation. 

For demonstrating the bacilli when they are scant in numbers we 
can very strongly recommend Biedert's method : A tablespoonful of 
sputum and two of water are mixed with four to eight drops of solution 
of soda (according to the condition of the sputum), and then boiled in 
a saucer, constantly stirring and gradually adding from four to six 
tablespoonfuls of water. The boiling is continued till a homogeneous 
fluid is formed. This is then centrifugated energetically or allowed to 
stand for two days (not longer) in a conical glass. Bacilli (and also 
elastic fibers) form a sediment. Then it is decanted, and a sample is 
removed with a perfectly clean instrument which is treated like a 
sample of sputum. In order to have it adhere it is sometimes necessary 
to add to each cover-glass a particle of untreated sputum of the same 
patient. Staining is done after the Ziehl-Neelsen method. 

Recently Dahmen has proposed to evaporate the sputum in a water- 
bath at 100° C. [212° F.], then triturate the sediment in an agate 
mortar and treat it on a cover-glass. The procedure is impractical, and 
is less certain than the preceding method. 

When one is not accustomed to examine for tubercle bacillus for 
the purpose of controlling the degree of staining, he should at the same 
time stain some sputum that is known to contain the bacillus [or he 
should keep test-slides on hand]. 

By these methods the tubercle bacilli are distinctly recognized by 
their red (or blue) staining. Since the spores that may be present are 
not stained, they may be seen in the interior of bacilli as clear points, 
and they may be so abundant as to cause the bacilli, when only slightly 
magnified, to look hke the chain coccus (Fig. 52). 
11 



1 62 SPECIAL DIAGNOSIS. 

The direct culture of tubercle bacillus, as has been accomplished by 
Kitasato, has no diagnostic significance. 

The number of bacilli found in a preparation depends, at least by the 
ordinary methods, very much upon chance, since only one or more 
particles of sputum at discretion are examined. Biedert's procedure 
rather permits one to draw some conclusion as regards the actual 
abundance of the bacilli in the lungs, but at best only an approximate 
estimate can be made in this manner as to the severity of the disease. 

The presence of this bacillus in the sputum indicates tuberculosis of 
the limgs (unless there may be tuberculosis of the larynx), and its diag- 
nostic value is so much the greater in that baciUi may often be discov- 
ered when the physical signs are indistinct or are altogether wanting. 

Absence of the bacilli at a single examination is without value, espe- 
cially when the sputum is scanty and not purely purulent. If they are 
absent in repeated examinations, this fact is to be considered with 
greater caution. On the other hand, in sputum that is not too scantily 
purulent the constant failure to find bacilli points with greater prob- 
ability against tuberculosis. It is to be understood that the staining 
material is as it should be,^ that the staining has been properly done, 
and that the most careful examination of the preparation has been 
made. In doubtful cases we recommend Biedert's sediment-process, 
described above, which gives tolerably certain success in finding bacilli 
when they are not numerous. 

Koch's tuberculin, of which we will speak again farther on, has, 
among others, certain effects upon the sputum of tuberculosis of the 
lungs, which effects are sometimes of diagnostic significance. In the 
first place, the sputum becomes more abundant, usually more rich in 
bacilli ; a sputum containing bacilli appears where before there was no 
sputum at all or no sputum containing bacilH. Besides, the bacilli 
very frequently show in a very decided manner the resemblance to 
chain cocci, mentioned above, and at the same time they frequently 
seem sharply bent, fallen to pieces, with the fragments lying together 
in irregular heaps. We here pass over these, and also the phenomena 
of Koch's reaction, since we refer to it again on page 164/. 

Pneumonia Cocci. — (ci) A. FrankcVs Pneumococcus. — These cocci 
appear in the sputum mostly in distinct capsules, and preponderantly, 
but not exclusively, as diplococci. They are oval or lance-shaped by 
becoming slightly narrower on the ends, which are turned in opposite 
directions. For the other characteristics compare Fig. 53. They may 
be stained by all anilin dyes, and are not decolorized by Gram's 
method, (b) Friedldnder s pneumococcus. It is very similar to the 
former, but it is decolorized by Gram's method, {c) Pio Foa's coccus, 
which is a diplococcus enclosed in a capsule. So far as we. know, it 
has only been found in the tissue-juice of pneumonic lungs, and has 
not been demonstrated in the sputum. It has great similarity to 
Frankel's coccus, both by its lancet form and because it can be 
stained by Gram's method. 

Frankel's coccus is found in the lungs and also in the sputum in a 
majority of cases of pneumonia. It is scarcely to be doubted that it is 
an exciting cause of pneumonia, not only of the genuine croupous, but 

^ See above. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 



163 




Fig. 53. — Frankel's pneumonia coccus, 
bred from the expectoration. Prepared by- 
Prof. Gartner. Oil immersion lens, one- 
twelfth ; eye-piece No. 4. 



also of certain secondary, forms. It has likewise been found in the pus 
of empyema and of cases of meningitis which complicated a croupous 
pneumonia. But it is sometimes also _^ 

found without any connection with 
pneumonia in pleuritis, metastatic 
meningitis, otitis, arthritis, in phleg- 
mons, in peritonitis with perforation, 
etc. This coccus seems, therefore, 
to produce not only croupous pneu- 
monia and its metastatic diseases, 
but also other forms of pneumonia 
and independent inflammations in a 
number of most different organs. It 
is a widespread, but frequently not 
very malign, exciter of inflammation.^ 

But Frankel's coccus is likewise 
found in the saliva of many healthy 

persons (about one-fifth of the healthy), and, according to later exam- 
inations, it is not distinguishable from the coccus of sputum septicemia. 

It is almost always found in the sputum, and most abundantly 
during croupous pneumonia, but, as can be understood from what has 
been said, it hkewise appears in catarrhal pneumonia, and also in all 
other possible sputa, and may be bred from them. From these facts 
its diagnostic significance is very greatly impaired. It can be con- 
founded with other similar cocci. 

Friedlander's coccus is most probably likewise an exciter of croupous 
pneumonia, but a very rare one. This coccus is, however, not only 
occasionally found in the sputum 
of a pneumonic patient, but it or 
some cocci microscopically sim- 
ilar to it is also found in the most 
different other sputa. 

Of Pio Foa's coccus we as yet 
know little. 

It is to be pointed out here 
that both croupous pneumonia 
and forms similar to it may be 
produced not only by invasion of 
the cocci of pneumonia, but also 
by streptococci and pyogenous 
staphylococci. 

Method of Staining the Pneu- 
mococci. — Frankel's coccus is stained after Gram's method in dry 
cover-glass preparations, and best with anihn-gentian-violet solution. 
From this it is immediately transferred to the decoloration fluid (iodin 
I.O; potassium iodid 2.0; aq. destil. 300.0) for two to three minutes, 
then to absolute alcohol to complete the decoloration. Frankel's 
cocci are intensely stained, but occasionally Friedlander's cocci are 
decolorized. Staining Friedlander's coccus : Dry-cover-glass prepara- 

^ It has lately been found by Pernice and Alessi {Riforma vied., 1890) in croupous 
pneumonia in all possible organs, some of which showed no inflammation at all. 



if V"* I 



'W 










W^m 



Fig. 54. — Actinomyces (after v. Jaksch), 



164 SPECIAL DIAGNOSIS. 

tions are put for a couple of minutes in a i per cent, solution of acetic 
acid. This is then blown away with a pipette ; it is dried in the air, 
placed in anilin-gentian-violet solution for a few seconds, then rinsed 
in water. Pio Foa recommends Gram's method for his coccus. 

Actinomyces. — In actinomycosis of the lungs or of the pleura, in 
isolated cases, this fungus is found in the sputum. I have observed it 
in the characteristic small kernels (see page 1 50). It is recognized by the 
sort of clubs, closely pressed together, which project from the surface 
of a confused mass which looks much hke detritus. We can best see 
the club-like projections without staining. The fungus can be distinctly 
stained by Gram's method. 

Of late several persons have succeeded in making pure cultures of 
actinomyces, but for diagnostic purposes pure cultures will only very 
exceptionally come into consideration. 

Mould (aspergillus, mucor) and isolated yeast-cells, when seen in 
the sputum, are without significance. The microbe of whooping-cough 
of Letzerich and Berger still needs confirmation. 

Moreover, the sputum always contains a great quantity of bacilH 
and cocci of all kinds, which no doubt come partly from the mouth and 
partly, probably, from the upper respiratory passages. The majority of 
these micro-organisms have no known pathogenic significance. It is 
of great interest, however, that there are micro-organisms in the sputum 
which are perfectly identical with certain pathogenic ones, but which 
in a given case do not produce the morbid phenomena proper to them, 
and so do not seem to be virulent — as, for instance, Frankel's and 
Friedlander's coccus of pneumonia. In this connection is to be men- 
tioned the fact that Loffler has found his diphtheria bacillus persisting 
in the mucus of the mouth for some time after recovery from the disease. 

4. Chemical Bxamination. — This has a minor place, considered 
with reference to diagnosis. 

There occur in the sputum albiuninous corpuscles in the form of 
mucin, nuclein, serum-albumin. The latter is very abundant in edema 
of the lungs. Kosselt asserts that peptone is found very abundantly 
in the sputum after the crisis of pneumonia. He also states that pep- 
tone is found, although in much smaller amount, in every purulent 
sputum. But this has lately been contradicted by Stadelmann. 

Temporary fatty acids occur very abundantly in gangrene of the 
lungs (Hoppe-Seyler, Leyden, and Jaffe). 

Finally, it is notable that in gangrene of the hings and bronchitis 
there is found a ferment hke the pancreas ferment (Filehne, Stolnikow). 
According to investigations by Stadelmann, it is present also in phthisi- 
cal sputum, although with considerably weaker effect. The same author 
has shown that the question is here probably not concerning an enzym, 
but about micro-organisms which produce a ferment-hke effect.^ 



As a sort of appendix we here add a few words on the use of 
Koch's lymph in diagnosis. TubercuHn, as is now well known, in 
certain considerable doses produces in tuberculous patients certain 
general and local phenomena which are comprehended under the 

^ Zeitschr. f. klin. Medicin, Bd. 16. 



EXAMINATION OF THE RESPIRATORY APPARATUS. 1 65 

expression '' reaction." This " reaction," and particularly the local 
signs of it, can be made use of for diagnostic purposes. It consists in 
certain subjective sensations in the respiratory apparatus (particularly 
pain), in phenomena pertaining to the sputum, of which we have 
already spoken on page 162, and in physical signs in the thorax. 
Although this local reaction is sometimes a very distinct test for the 
presence of tuberculosis in the lungs, and also for tuberculosis of the 
most different organs formerly latent, yet we cannot unconditionally 
recommend its use for purposes of a diagnosis of pulmonary tuber- 
culosis, because it requires doses which in some cases produce an 
exacerbation of the disease, which sometimes results in accelerating its 
progress. It is a different matter if tuberculin is applied for a diagnosis 
of tuberculosis of organs less important to life ; for instance, of the 
bones. Here the procedure seems to have a proper application, but it 
must be omitted if neighboring organs important to life could be 
harmed by the local reaction — as, for instance, in tuberculosis of the 
spinal column, of the skull, and of the pelvis. 



CHAPTER V. 
EXAMINATION OF THE CIRCULATORY APPARATUS. 

EXAMINATION OF THE HEART, 

The development of the methods of local examination of the heart 
is closely connected with the introduction of percussion and ausculta- 
tion. So we have here also chiefly to thank Laennec and Skoda, as 
well as Piorry, Friedreich, Bamber, and Gerhardt. 

Anatomy of the Normal Heart. 

The heart lies upon the diaphragm, sloping obliquely forward in 
such a way that its long axis is inclined forward and toward the left. 
It extends from about 8 or 9 centimeters to the left of the median line 
(apex of the heart) to about 4 or 5 centimeters to the right of the same 
[i. e. about one and a half finger-breadths to the right of the right bor- 
der of the sternum — right auricle), so that about two-thirds of the heart 
is in the left half of the chest and one-third in the right half Its 
highest point (the . left auricle) is at the lower border of the sternal 
insertion of the second rib, its lowest point at the upper border of the 
sixth costal cartilage or the fifth intercostal space (see Fig. 55). The 
three borders of the heart are formed as follows : the right by the right 
auricle, the lower by the right ventricle, and the left by the left ventri- 
cle. Only a small portion of the latter lies on the anterior surface, 
much the greater part of which is formed by the right ventricle. 

The figure (Fig. 55) shows how the lungs glide over the heart, so 
that only a small four-cornered portion, belonging exclusively to the 
right ventricle, is in contact with the wall of the chest. Of the borders 
of this superficial part of the heart, the one toward the right lies between 
the middle line and the left sternal line, the upper behind the fourth 
rib, the left somewhat outside of the left parasternal line. Below, the 
heart is in relation with the liver in such a way that it overlaps the 
latter with its lower border. It can be seen from the course of the line 
c d, which indicates the complementary space of the incis2ira cardiaca 
lob. sup. sinistra, that a considerable portion of the heart which is in 
contact with the chest-wall would become still smaller if the lung 
should completely fill the complementary space. 

These are the location and extent as they are found in the adult in 
the dorsal or upright position. With children the heart (as well as the 
diaphragm and the lower borders of the lungs) is about one rib higher. 
It is also, since it is proportionately larger, to a larger extent in con- 
tact with the wall of the chest ; with increasing age, on the other 
hand, it moves lower down, to the lower border of the sixth rib (the 

166 



EXAMINATION OF THE CIRCULATORY APPARATUS. 



i^y 



sixth intercostal space) with a smaller portion parietal, since the lungs 
lie over it to a larger extent. In the side position, especially on the 
left side, the heart always sinks very considerably to the lower side.^ 




Fig. 55.— Position of the contents of the thorax, of the stomach, and of the hver. from in 
front ( Weil-Luschka). The portions of the heart and Hver which are drawn with unbroken 
hatched hnes represent the extent to which these organs are in contact with the chest-wall. 
The portions that are not in contact with the chest-wall, but are covered by the lungs, are 
represented by broken (clear) hatched lines. 

ef, border of the right lung; g h, border of the left hing; a b and c d {. . . .), the boundaries of the 
■complementary pleural sinus; /, boundary between the upper and middle lobes of the right lung; k, boun- 
dary between the middle and lower lobe of the right lung ; /, boundary between the upper and lower lobe of 
the left lung; w, stomach (greater curvature). 

Situs viscerwn inversus exhibits the heart in such a way that 
■** right " and '* left " are exactly reversed, like the reflection in a mir- 
ror. Hence we need not say anything more about it. 



PRELIMINARY REMARKS NECESSARY TO UNDERSTAND THE PHYSI- 
CAL PHENOMENA OF THE HEART. 

What follows is a brief explanation of those facts regarding the 
physiology and the general pathology of the heart which must be 
always kept in mind by the educated physician in examining and 
forming a judgment of the heart: 

I. The Movement of the Blood in the Heart. — The blood flows from 
the body through the cavcB into the right auricle, whence, during the 
ventricular diastole, it passes through the right auriculo-ventricular 
opening, the tricuspid valve, into the right ventricle, being urged for- 
ward toward the end of the diastole by the weak muscular contraction 
of the right auricle, and at the same time, in a peculiar manner which 
cannot be described here in detail, lifts the auriculo-ventricular valves 

/^ See under Apex-beat. 



1 68 SPECIAL DIAGNOSIS. 

SO that they are prepared for closing. The systole which immediately 
follows drives the blood out of the ventricle, through the open pulmo- 
nary semilunar valve into the pulmonary artery, the tricuspid valve being 
at the same time closed. The blood, prevented from flowing back 
into the ventricle during the diastole which immediately follows by the 
closure of the pulmonary semilunar valve, passes through the lungs, 
and from them flows into the left auricle ; whence, by the diastole of 
the ventricle, it flows through the left auriculo-ventricular opening, the 
mitral valve, into the left ventricle, whither it is again assisted at the 
end of the diastole by the contraction of the auricle. The left ventricle 
discharges its contents during the systole (the mitral valve being 
closed) into the commencement of the aorta, through the aortic mouth, 
which it opens by an actual pressing open of the clack-valve of the 
semilunar aortic valves ; but as soon as the pressure from the ventricu- 
lar side sinks again, because its diastole begins, then the semilunar 
valves again close ; the blood which has been forced from the ventricle 
into the comis aortcB has its only outlet into the body. 

On page 170 are given more details as to the manner in which the 
contraction of the ventricles takes place, and its relation to the closing 
of the semilunar valves and the beat of the apex. Our knowledge of 
these points has recently been greatly extended. 

2. Valvular Insufficiency , and its Effects upon the Movement of the 
Blood. — From the foregoing it is evident that the openings of the 
heart are very important factors, on the one side being the entrance 
and exit of the ventricles, and on the other being the location of the 
valves of the heart which hinder any backward flow of the blood. 
The motion of the blood can only in two ways be interfered with by 
pathological processes at the openings of the heart — either by nar- 
rowing at the opening (stenosis of valve) or by the valves losing their 
power to close {insufficiency of the particidar valve). Stenosis of a valve 
may be caused by products of endocarditis, which cause adhesion of the 
flaps of the valve, with formation of a cicatricial narrowing ring at the 
base of the valves. Insufficiency may likewise be caused by endocardi- 
tis (general shortening of the flaps and of the tendinous processes of the 
papillary muscles), and this is the most frequent cause of insufficiency ; 
but the condition may also arise from a distention of the opening, so 
that the flaps are too short to close it {relative valvular insufficiency in 
weak heart with dilatation). 

An opening that is narrowed hinders the passage of the blood 
through it. If it is an auriculo-ventricular opening {mitral or tricuspid 
stenosis), then, at the moment of diastole of the heart, the blood is 
hindered in its entrance into the ventricles — there is imperfect filling of 
the ventricles ; if it is an arterial opening that is narrowed {aortic or 
pidmonary stenosis), then the exit of the blood from the ventricles is 
interfered with at the systole. If the valvular mechanism is in such a 
condition that it cannot perfectly close, then at the moment when it 
ought to close it allows a part of the blood to flow backward. If the 
difficulty is with the entrance to the ventricles {insifficiency of mitral or 
tricuspid valve), then with the systole a part of the contents of the ven- 
tricle flows back into the auricle ; but if the deficiency is at the outlet 
of the ventricle {insufficiency of the aortic or pulmojtary valve), then at 



EXAMINA TION OF THE CIRCULA TOR V AFFARA TUS. 1 69 

the end of the systole, during the diastole which follows, a part of the 
blood that has just been thrown into the artery will be thrown back 
into the ventricle. 

In one respect all the defects that have been mentioned are ahke : 
they check the blood-current; they cause a stasis of blood in that 
chamber of the heart which is, with reference to the direction of the 
blood-current, just behind the defective opening. Thus, a defect of an 
arterial opening causes stasis in the corresponding ventricle ; a defect 
in an auriculo-ventricular opening occasions stasis in the corresponding 
auricle, and also beyond this in the corresponding veins. 

3. Compensation ; Accommodation of Valvular Deficiency. — The ab- 
normal resistance which is exerted against the blood-current from the 
valvular defect would immediately lead to more considerable disturb- 
ances of the blood-current if it were not promptly equalized by the 
increased work of that section of the heart lying (in the course of the 
blood-current) above the point of resistance. But this does not con- 
tinue, for with increased work the overloaded section of the heart 
becomes hypertrophied — compensatory hypertrophy. This condition is 
extremely simple in defects at the aortic opening : they are compen- 
sated by hypertrophy of the left ventricle, which is associated with 
dilatation {eccentric dilatation). The latter is especially marked in 
insufficiency of the aortic valve, and this is explained by the fact that, 
with aortic insufficiency, during the diastole the left ventricle receives 
blood from two sources, hence very much more than normal. With 
mitral insufficiency the auricle must accommodate for the defect ; but, 
notwithstanding the fact that it becomes dilated and hypertrophied, it 
cannot perform the necessary work, cannot overcome the stagnation : 
the accumulated blood passes through it to the veins, capillaries, and 
arteries of the lungs, and so on till it reaches the right ventricle ; this 
becomes dilated and hypertrophied, and thus causes the increase of the 
propulsive power necessary for the accommodation. 

Though defect of the valve of the pulmonary artery is rare, the 
actual consequences are the same as of defect of tlie aortic valve; 
but defect of the tricuspid, which, with the exception of relative 
insufficiency, is likewise rare, only produces accommodation of 
hypertrophy of the right auricle, but to a degree hardly to be men- 
tioned, for the increased pressure in the general venous system has 
no effect upon the pressure in the arteries of the body, and hence 
cannot produce any notable compensatory hypertrophy of the left 
ventricle. 

Thus, insufficiency and stenosis of the aorta cause hypertrophy of 
the left, and insufficiency and stenosis of the mitral valve hypertrophy 
of the right, ventricle. But with mitral insufficiency something more 
follows : during the diastole of the left ventricle there flows into it 
from the dilated auricle the blood which has accumulated there under 
very much increased pressure and in increased quantity ; it becomes 
dilated, and, since it also has to dispose of the increased quantity of 
blood, which it does by driving part of it forward into the aorta and 
part backward through the mitral orifice into the auricle, it also 
becomes hypertrophied. Hence, mitral insufficiency leads to hyper- 
trophy and dilatation of both ventricles. 



I/O SPECIAL DIAGNOSIS. 

These different hypertrophies are aids in the diagnosis of the 
individual valvular lesions, 

4. Hypcrtropliy of the Heart from Other Causes. — Besides the val- 
vular defects, certain other conditions lead to hypertrophy : thus, the 
left ventricle becomes hypertrophied by the increased resistance in the 
general arterial system produced by sclerosis of the arteries ; it some- 
times results from continued excessive muscular exertion {idiopathic 
hyperti'ophy), further, from different forms of clironic nephritis, and in 
this it is more marked the longer the general vigor is maintained 
(hence most marked in renal atrophy) ; finally, also in acute nephritis, 
if it lasts long enough. The right ventricle becomes hypertrophied 
whenever there is continued increased resistance in the pulmonary cir- 
culation, most regularly and markedly in emphysema (from destruction 
of the capillaries of the lungs from atrophy of the tissue), in marked 
contraction of the lungs, in marked kyphoscoliosis. 

5. TJie form of the lieart is changed in consequence of the hyper- 
trophy (and dilatation) : hypertrophy of the left ventricle broadens the 
heart to the left and somewhat lengthens it ; if there is dilatation also, 
the broadening to the left is still more increased. Hypertrophy and 
dilatation of the right ventricle simply broaden the heart to the right. 
Hypertrophy and dilatation of both ventricles broaden the heart in 
both directions and lengthen it. 

6. Simple Dilatation. — This results entirely from weakness or 
paralysis, and is dependent upon a diminished tone of the heart- 
muscle, with a simultaneous loss of its power to contract. It may 
also occur in a heart that was previously dilated and hypertrophied, 
and it then results in a very great enlargement of the heart. In 
dilatation of the heart the enlargement is nearly symmetrical in all 
directions. 

The diagnosis between enlargement of the heart from hypertrophy 
(with dilatation) and the dilatation just mentioned is chiefly made by 
the consideration of the evidences of the amount of work the heart is 
doing. 

7. The extent to which the heart is in contact with the chest-wall is in 
very close relation to the size of the heart.^ An enlarged heart always 
has a larger area in contact with the chest-wall than does a normal 
heart if there are no conditions in the neighborhood of the heart which 
keep it away from the chest-wall or hinder an increase of its parietal 
contact. The area of its parietal control may be diminished by emphy- 
sema of the lungs or by an increase in the volume of the lungs, whether 
from anomaly of both lungs or only of the left lung, either chronic or tem- 
porary. In every case the distended lungs endeavor, as it were, to put 
themselves, to some extent or entirely, between the heart and the thora- 
cic wall ; that is, to interfere with the parietal position of the heart. In 
such a case we speak of the overlying of the heart by the lungs. In 
emphysema a smaller area of the heart is in contact with the thoracic 
wall than when the lung is normal. Likewise, when the heart is 
enlarged, if at the same time there is emphysema, it does not show 
itself by a more pronounced parietal position. Hence, w^hen these two 
conditions exist simultaneously, enlarged heart and emphysema, the 

^ Regarding the pericardium, see later. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 171 

heart may be in parietal contact to a degree corresponding to the nor- 
mal, or even to a more or less diminished area. 

Another condition has a contrary influence : this is an inflammatory 
adhesion of the border of the lung with the parietal pleura at the 
incisura cardiaca. This not only prevents all respiratory movement 
of the edge of the lungs over the front of the heart, but there is also a 
recession of the lungs from over the heart through a simultaneous 
shrivelling of the pleura and of the lungs. Thus, the heart is parietal 
to a larger extent than is proportionate to its size if the lungs were of 
normal size. Enlargement of the heart is simulated by the heart 
having an abnormally large free space in front of it. 

Hence, in forming an opinion as to the size of the heart from the 
extent to which it is in contact with the chest-wall we must always 
bear in mind the possibiHty of the presence of these conditions.^ 

Inspection and Palpation of the Region of the Heart.^ 

Both these methods of examining the heart, like the foregoing, will 
be best practised in a moderately high dorsal position. There are 
technical difficulties in examining a patient either standing or sitting, 
but sometimes in severe heart-diseases the latter cannot be avoided on 
account of the existence of orthopnea. Palpation may be performed 
either with the tips of the first and second fingers or with the flat, bare 
hand. 

The Apex-beat. — Normal Conditions. — The apex-beat is of the 
greatest importance as an anatomical starting-point, for it corresponds 
either exactly to the apex or to a spot very close to it a little nearer to 
the median line. In the majority of healthy persons it is recognizable 
by the eye, as well as by the finger applied to the spot, as a rhythmical 
and systolic projection forward about the breadth of the finger, which 
in the adult in the upright or dorsal position occurs in the fifth inter- 
costal space just within the mammillary line; only exceptionally, 
chiefly with persons with very short chest, it is found in the fourth 
intercostal space. In children, up to the age of ten years, it is usually 
found in the fourth intercostal space, and either in the mammillary line 
or just outside of it.^ In old age, on the contrary, it is sometimes 
found in the sixth intercostal space. Much fat or the mamma, also 
narrow intercostal spaces, render it invisible, but yet it may generally 
be felt. Moreover, without a distinct cause, it may sometimes be 
entirely wanting in healthy persons. 

Quiet breathing produces no change in the apex-beat. With deep 
inspiration it is covered by the distended lung, which then occupies the 
complementary space ; if it be still evident, it moves sometimes an 
intercostal space lower down, corresponding to the inspiratory sinking 
of the diaphragm. 

The effect of change of posture is very noticeable in the side posi- 
tion : the left-side position moves the apex-beat outward beyond the 
mammillary line, even as far as the anterior axillary line ; the right- 

^ See percussion of the heart : I. Absolute heart-dulness. 

2 The two methods of examination have such close connection with reference to the 
heart that to separate them would seem to be artificial. 

^ See above in the section on the Anatomy of the Normal Heart. 



1/2 SPECIAL DIAGNOSIS. 

side position causes the beat to disappear or moves it somewhat to the 
right. 

Physical exertion and mental excitement, the chief physiological dis- 
turbers of the heart's action, may noticeably change the apex-beat in 
perfectly sound persons, but still more in nervous persons : it may 
become plainly stronger and even broader or move somewhat to the 
left. 

The physical conditions of the apex-beat and its relation in time to 
the phases of the revolution of the heart have been for a long time the 
subject of manifold examinations. Only lately have these questions, as 
it seems, finally been made clear by Martins. His procedure is as 
follows : He notes in the curve which he causes the heart-beat to write 
by a Gunmach's polygraphion the moments of the first and second 
heart-sounds — /. e. of the closure of the auriculo-ventricular and arterial 
ostia. This is accomplished with almost absolute exactness by simul- 
taneous auscultation, but only under one condition — i. e. if the heart 
beats perfectly regularly. In this case the movements of the marking 
hands are just as exactly in harmony with the heart-sounds as regards 
time as in dancing the movements of the feet are in harmony with the 
notes of the music, or as in playing a duo the movements of the fingers 
of the piano-player with those of the violin-player. Martins calls his 
method " acoustic marking method." 

The most important thing in the results of these investigations is the 
irrefutably demonstrated proof of the relation in time of the apex-beat 
to the systole of the heart. The apex-beat falls about in the middle 
between the closing of the auriculo-ventricular and arterial valves ; and, 
as Martins farther on, by synchronous observation of the curve of the 
carotid and that of the apex-beat, for the first time proves exactly that 
the beginning of the streaming of the blood into the aorta coincides 
with the highest point of the cardiogram — /. e. with the summit of the 
apex-beat — it follows necessarily that the ascending branch of the curve 
of the apex-beat, which lies between the closing of the auriculo-ventricu- 
lar valves — i. e. the beginning of the systole and the opening of the 
ostium aortae — corresponds with a space of time during which the ven- 
tricle contracts, but has not yet reached that external pressure which 
overcomes the pressure in the aorta, and which thus opens the semi- 
lunar valves. Therefore there is a time in this first part of the systole 
when the ventricle is closed both forward and backward (Verschlusszeit). 

The heart-beat is therefore formed during this '' Verschlusszeit," 
which is a refutation of the recoil theory propounded by Alderton, 
Skoda, and Gutbrod. It is rather the change of form and position of 
the hardened ventricle which produces the impulse, as Ludwig and 
others recognized previously, but never exactly proved. 

Displacement (Dislocation) of the Apex-beat in Disease. — 
It may be brought about — {a) by dislocation of the heart, {b) by en- 
largement of the heart. 

(a) Dislocation of the Heart. — The apex-beat is a very important 
sign for determining this, since the other metliods often have a very 
indefinite result or may entirely fail. 

Deformity of the tJwrax may cause displacement in all possible 
directions. It may happen that in a chest that is flattened or pressed 



EXAMINATION OF THE CIRCULATORY APPARATUS. 1 73 

in in the neighborhood of the heart the apex-beat (likewise the heart) 
will be found considerably outward or considerably inward. 

Emphysema of the lungs, in case the apex-beat is not lost by the 
overlapping, presses it down into the sixth intercostal space (depression 
of the diaphragm). 

In exudative pleiLvitis and pneinnotJiorax the heart and apex-beat 
are pushed toward the sound side, in the worst cases as far to the left 
as the middle axillary line, but to the right very rarely beyond the 
mammillary line. Likewise, the mediastinum and the base of the 
heart move over, although not so far as the apex. Mediastinal tumors 
may have the same effect as pleuritis of the right side. 

In pleurisy of the right side the apex is sometimes pushed not only 
to the left, but also upward into the fourth intercostal space. We are 
not certain why this is so. It is highly improbable that the left lobe 
of the liver rises up while the right is dragged down, for the point of 
traction, at the suspensory ligament, brings it still lower by the pressure 
of the exudation upon the right side. The location of the heart when 
pressed upon is subject to many disturbances which we cannot describe 
at this time. 

Slirinking of the lungs and of the side of the chest after a pleuritis 
draws the mediastinum and the heart into the diseased side, and at the 
same time draws the diaphragm up ; hence in shrinking of the right 
side the heart moves upward and to the right side, but in disease of the 
left side it is drawn upward or upward and to the left. 

If the heart chances to be drawn to the right so much as to bring 
it under or close up to the sternum, where the intercostal spaces are 
very narrow, of course we cannot observe the apex-beat. 

In exudative pleiudtis it sometimes happens that the heart becomes 
fixed by inflammatory adhesions, and then the apex-beat remains in 
the new position even after the cause of the displacement has been 
removed. 

Elevation of the diaphragm as a result of peritonitis or of simple 
mechanical pressure from below, or from neurotic paralysis of the 
diaphragm, causes dislocation of the heart upward or upward and to 
the left. 

{b) Enlargement of the Heart. — Hypertrophy and dilatation of the 
left ve7ttricle are made manifest by displacement of the apex-beat out- 
ward or outzvard and dozunward, and under some circumstances as far 
as to the posterior axillary line and the eighth intercostal space. The 
apex-beat is also broader and stronger.^ 

The conditions which bring about hypertrophy and dilatation of 
the left side have been referred to on page 170. Likewise, hyper- 
trophy and dilatation of the right ventricle displace the apex-beat a 
little toward the left, since the large right ventricle pushes the left 
somewhat to one side. But the displacement is always quite small, at 
most not beyond the mammillary line. 

Alteration in the Width and Strength of the Apex-beat. — 
We judge of the breadth both by inspection and palpation. We 
seldom have an increase in the breadth without an increase in the 
strength as well : in the normal heart, if it becomes parietal over a 

^ See below. 



174 SPECIAL DIAGNOSIS. 

larger area from shrinking of the lungs ; moreover, I have sometimes 
seen it with deformity of the chest (without hypertrophy of the heart), 
and where there was marked wasting, so that the patient was very 
lean. 

As a rule, breadth of the apex-beat is associated with a strong beat. 

The strength of the apex-beat can only be made out by palpation. 
By constant practice with the hand it can be distinctly recognized. 
An apex-beat that is so strong that it lifts the finger that is moderately 
pressing over it is called " heaving." 

Temporary, often notably strengthened and moderately broadened, 
impulse is caused by increased heart-work ^ in consequence of exertion 
and mental excitement. For this reason, when these two conditions can 
be excluded, the heart ought always to be examined. 

In nervous palpitation, Basedow's disease, and sometimes in cJironic 
7iicotin-poisoning the heart-beat may for a time be very much stronger, 
and even somewhat broader, as an indication of the increased work of 
the heart, without any organic change in it. The same thing occurs, 
though in a moderate degree, m fever. Moreover, the apex-beat may 
be stronger if the heart is pressed firmly against the chest-wall, as in 
mediastinal tumors, although the heart's work is not increased. 

Contimied strength and breadth of apex-beat is the most important 
sign of hypertrophy of the left ventricle. In well-marked cases the 
beat is ** heaving," and is as wide as several fingers, being displaced 
toward the left and downward.^ 

It is assumed that an enlarged heart works with strength increased 
in proportion to its increased volume. If the heart becomes weak, then 
there is a diminution as regards the breadth and strength, and yet it 
may be distinctly recognized as diseased. 

In many cases it is difficult to separate the apex-beat from the 
" heart-beat " in general.^ 

Weakening of the Apex-beat. — It has been mentioned already that 
the apex-beat may be weak in persons who are perfectly healthy, or it 
may be entirely wanting. 

Pathologically, it is diminished or lost — 

{a) By the activity of the heart being concealed by overlapping ; from 
emphysema of the lungs, by a pleuritic or pericardial exudation, and by 
tumors. 

(b) By edema, empJiysema of the skin, inflammatoiy diseases of the 
chest-wall in the neighborhood of the heart. 

(c) By diminution of the work of the heart, as takes place with any kind 
of degeneration of the heart-muscle : here we may mention myocarditis, 
lipomatosis cordis, weakness or degeneration of an hypertrophied heart, 
especially with incompensation, with valvular deficiency, weakness in 
febrile diseases (especially collapse). 

The disappearance of an apex-beat which has previously been dis- 
tinct is sometimes the only sure, and hence is a very important, sign 
of the development of exudative pericarditis. But diminution of the 
work of the heart is more distinctly declared at the radial pulse than 
by the apex-beat.^ Moreover, the radial pulse is the only direct 

^ See above. ^ See above. 

2 See below, p. 176. * See below for the significance of all these conditions. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 175 

measurer of what the heart does in all the above-mentioned cases of 
concealment of the work of the heart. It is especially important in 
pericarditis. 

Where the apex-beat is covered by fluid in the pericardium it often 
again becomes distinct when the patient sits up or bends forward, 
because then, on account of its greater weight, the heart rests against 
the chest-wall. It is then often found in the sixth intercostal space, 
because the distended pericardium presses the diaphragm down. This 
sign, of course, is wanting in cases where the apex-beat is missed from 
weakness of the heart. 

Further, the apex-beat is wanting where there are pericardial adhe- 
sions} and sometimes in stefiosis of the coniniencement of the aorta, and 
this notwithstanding the existence of hypertrophy of the left ventricle 
(slow ventricular contraction resulting from difficulty in emptying 
itself). 

So far as experience goes, " systolic drazving-in " in the neighbor- 
hood of the apex-beat has no diagnostic value.^ 

Doubling of tJie Apex-beat : Systolia Alter nans ; Hemisystolia. — There 
are cases of abnormal activity of the heart where, of two single revolu- 
tions of the heart's action, during the first the observer gets the idea 
that the work is accomplished chiefly, or even exclusively, by the left, 
and that of the second by the right, ventricle. Unverricht has observed 
in a mitral insufficiency that in the one contraction of the heart there is 
a vigorous impulse of the apex, a mitral murmur, and a diastolic aortic 
sound ; in the other, that a weak heart-impulse, more to the right, a 
diastolic pulmonary sound, and epigastric pulsation were more distinct. 
Leyden, who first directed attention to this condition, has described 
cases where the phenomena gave rise to the supposition that there was 
an alternating contraction of the ventricles ; one time both, and the next 
time only the right one, contracted, so that to one contraction of the 
left ventricle there were two of the right. The latter Leyden has called 
hemisy stole ; the former Unverricht denominated systolia alternajis. 

Some believe that in such cases there is simply bigeminate with an 
alternating relation of the contractions of the heart.^ We cannot 
refrain from making the remark here that to-day the terms ** bigemi- 
nate " and " alternating " action of the heart are frequently misapplied,^ 
and that this confusion is increased by Unverricht's denomination, 
''systolia alternans,'' which, in truth and justly, should correspond with 
the alternating pulse. 

The application of the graphic method to the impulse of the apex 
(cardiography) has, as has been mentioned before, advanced our under- 
standing of the course of the heart's revolution in a high degree, espe- 
cially the recent work of Martins. But as regards pathology, and 
especially for diagnostic purposes, this method has not yet produced 
any results worth mentioning. 

The Neighborhood of the Heart in General. — Prominence of 
the neighborhood of the heaj^t, bulging, including the ribs and sternum, 

1 See below under Systolic Retraction. 

2 Regarding systolic retraction of the entire region below the heart, see below. 
^ Compare under Examination of the Pulse. 

* Compare under Pulsus Alternans and Bigeminus. 



176 SPECIAL DIAGNOSIS. 

takes place gradually in marked hypertrophy and dilatation : in hyper- 
trophy of the right ventricle or of the right and left the bulging some- 
times extends to the right side of the sternum ; in hypertrophy of the 
left ventricle alone it lies more to the left. Pericarditis exudativa some- 
times causes a distinct swelling. 

This sign depends upon two factors — the size of the heart or of 
the pericardium, and the flexibility of the chest-wall. If the latter is 
marked, -the swelling develops quickly, as in acute pericarditis, and is 
very marked (enlargement of the heart in children) ; when the thorax 
is rigid there may be no projection, though the heart is very large. 
This condition is not to be confounded with the pressing forward of 
the heart from mediastinal tumors or aneurysm. 

Generally when there is a broad heart-beat in the intercostal spaces 
in the neighborhood of the heart, and even upon the ribs and sternum, 
it is from a hypertrophy of the heart. But also, when there is contrac- 
tion of the left lung, with the heart free from attachment, the motions 
of the heart may be seen as well as felt over a broader extent in the 
intercostal spaces. If in such cases the heart's action is excited, there 
is the impression of a notable hypertrophy of the heart, even when the 
heart is quite normal in size. 

If the heart, from dilatation or retraction of the lungs, is more 
extensively parietal, weakness of the heart occurs, then we not infre- 
quently see a broader waving in the intercostal spaces, and even on the 
ribs of the precordial region, which, however, by its evident lack of 
energy, is visibly in contrast with its former circumscribed but powerful 
motions. 

Martins has sometimes seen, in simple over-exertion of the heart by 
bodily activity, not only the above condition, but even an extremely 
strengthened apex-beat, and visible and palpable heaving of the whole 
precordial region, with synchronous weakness of the pulse. He con- 
siders this contrast between visible labor of the heart and the pulse to 
be pathognomonic of pure over-exertion of the heart, provided stenosis 
of the aorta or aneurysm can be excluded. 

Pidsations at the base of the heart sharply limited to the second 
intercostal space on the right and left sides of the sternum come from 
the aorta or pulmonary artery. They are rarely visible ; generally 
they can only be felt. If they are systolic, they may indicate aneurysm 
of these vessels. More frequently we may feel a diastolic shock, 
especially upon the left, over the pulmonary artery. If the lungs and 
heart are normal, it cannot be felt ; but if the lungs are drawn back 
from the base of the heart (by shrinking or by enlargement of the 
heart), or if there is thickening, then it may be felt, especially if it is 
simultaneously strengthened by hypertrophy of the right ventricle. 
In emphysema of the lungs there exists the peculiar condition that, 
although the closure of the pulmonary valve is in a marked degree 
stronger, yet it cannot be made out because the inflated lung lies 
over it. 

Pulsation in the region about the heart occurs in empyema located 
near the heart upon the left side (empyema pulsans) ; farther, in aortic 
aneurysm} 

^ See this. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 1 77 

Although systolic drawmg-in at the apex of the heart is of no 
significance/ yet systolic drawing-in of several intercostal spaces in the 
neighborhood of the heart, but especially of the ribs and the lower 
part of the sternum, is of diagnostic value : it is probable that there is 
pericarditis adhcesiva with mediastinal pericarditis, accompanied by 
thickening. But yet these signs may be entirely wanting, although 
the condition is present ; and, on the other hand, they may be observed 
in cases where this condition does not exist. The drawing-in may be 
caused by a dense mediastinum being adherent to the spine, and again 
by pericardial adhesion to the chest-wall ; its contraction — that is, its 
constantly becoming shorter — must of necessity cause a drawing-in of 
the chest-wall. 

''Buzzing'' and friction-sounds that can be felt in the neighbor- 
hood of the heart accompany very marked endocardial or pericar- 
dial sounds.^ 

The epigastrium. — In inspecting and palpating the heart this 
must always be considered. Systolic trembling, or even systolic pidsa- 
tion, may be observed here if the heart, more particularly the right 
ventricle, is drawn nearer the abdominal wall by the depression of the 
diaphragm, but especially is this the case when, at the sam£ time, the 
right ventricle is hypertrophied : in emphysema of the lungs. 

This epigastric pulsation must not be confounded with that which 
is to be seen from the abdominal aorta when the abdomen is very 
empty and the abdominal wall very thin, whether the aorta pulsates 
normally strongly or not, or whether or no there is an aneurysm of the 
abdominal aorta. This pulsation is, moreover, best transmitted when 
a tumor of the lymphatic glands, of the stomach, or a thin but firm 
liver lies over the aorta. Sometimes (not always) the pulse is felt 
noticeably later than the systole of the heart. 

Percussion of the Heart. 

This has for its object the determination — 

1. Of the absolute " small " dulness of the heart, which corresponds 
with the portion of the heart that is in contact with the chest-wall, and 
which has an almost definite relation to the size of the heart. 

2. The so-called relative heart-dnlness, which lies above and to the 
left of the absolute dulness, and which is determined by the thinness 
of the lungs around its border.^ It often stands indirectly in some 
relation to the size of the heart, but only exceptionally represents the 
real size of the heart. 

To these two Ebstein has recently added — 

3. Palpatory percussion of the " hearts resistance',' which is deter- 
mined by ascertaining the anatomical size of the heart. 

Normal Percussion Figure of the Heart. — Methods of Per- 
cussion. — I. Absolute Heart-dulness. — This is determined by light per- 
cussion, and corresponds, in fact, to the portion of the heart that is 
parietal. In two respects it departs from this, though not essentially : 
the small strip of the heart which is parietal behind the sternum 

^ See above. 2 ggg under Auscultation of Heart. 

^ See above, p. 108. 
12 



i;8 



SPECIAL DIAGNOSIS, 



between its left border and the inner border of the right lung is not 
dull, as would be expected, but gives a clear sound, as indeed occurs 
over the whole surface of the sternum ; ^ the lingula, being so small, 
does not affect percussion ; over it we notice absolutely deadened 
sound. Thus we have the following figure of the absolute heart- 
dulness in persons in middle life (Fig. 56) : the boundary on the right 
is the left sternal line ; the upper boundary lies upon the fourth rib ; the 
left boundary is outside of the left parasternal Hne. The lower bound- 
ary toward the liver cannot be exactly determined, it being defined by 
the apex-beat, and generally also by the upper border of the sixth rib. 
In children the area of heart-dulness (absolute) is somewhat greater, 
the heart being relatively larger : the upper boundary in the third inter- 
costal space ; hence the apex-beat is generally in the fourth intercostal 
space ; the left boundary near the mammillary Hne ; in old age, however, 
it is smaller (from inflation of the lungs), about over the fifth rib or the 
parasternal line. 

In quiet breathing the dulness does not distinctly change ; in deep 
inspiration it is very decidedly diminished or entirely disappears, 




Fig. 56. — Percussion-boundary of the lungs in front (Weil) : 

gh, the upper limits of the lungs; e f, the lower limits of the lungs ; b d, boundary between the lungs 
and heart at the incisura cardiaca. I'he strongly-hatched surface represents the portions of the heart and 
liver that are in contact with the wall of the chest; the lighter hatching, the so-called relative heart and 
liver-deadness (see later) ; m, spleen-deadness. 



because the costal cartilages come close together at the sternum.^ It 
makes no difference whether the examination is made in the dorsal or 
the upright position. Examination upon the side makes considerable 
alteration of the area of dulness. 

^ See above, p. 106. 

2 Compare the course of the boundary of the complementary space (Fig. 55). 



EXAMINATION OF THE CIRCULATORY APPARATUS. 1 79 

The beginner is apt to be much confused, because sometimes in a 
considerable part of the location of heart-dulness, even within the 
entire region, he will find a tympanitic-deadened resonance which 
downward, but without a distinct limit, changes into a pure tympanitic 
resonance. This is especially frequent in short persons with a short, 
thick thorax and a full abdomen. The resonance is from the stomach, 
which lies under the heart, and is more promptly elicited by strong 
than by weak percussion. When there is an otherwise normal condi- 
tion of the heart and lungs this phenomenon has no pathological 
significance. 

It is very difficult to judge of the absolute dulness of the heart, par- 
ticularly in pathological cases : it denotes the parietal position of the 
heart, which, however, depends not only on the size of the heart, but 
also on the size of the lungs, the latter of course in a reversed sense. 
This circumstance makes it very difficult to form a conclusion as to the 
size of the heart from the extent of the absolute dulness ; however, any 
one who, in judging of the percussion figure of the heart, accustoms 
himself every time to take exactly into consideration the condition of 
the lungs minimizes to a great extent every difficulty. But in many 
cases the result of the examination still remains entirely in doubt. 

2. Relative Heart-dulness. — This forms a border around the abso- 
lute dulness to the left and above it, and it corresponds with the 
thinned-out portion of the lungs. It is revealed by stronger and, in 
its upper part, by comparative percussion. It no doubt depends, with- 
in certain limits, upon the delicacy of the perceptions of the indi- 
vidual making the examination as to where he will fix the limits 
between it and those of normal lung-sound ; for, in the first place, 
on account of the very gradual transition of the sound, the indi- 
vidual perception of hearing is a large factor here ; in the second 
place, according to explanations already made, the size of this rela- 
tive dulness depends upon the degree of intensity of percussion, 
for which degree we unhappily do not have an absolute measure. 
One who percusses very carefully and, above all, always with about 
equal force, will accustom himself by and by to a somewhat equal 
judgment of the relative dulness of the heart in one case as compared 
with another. And, again, for determining the size of the heart the 
relative dulness has an important, and not seldom a greater, value than 
the absolute dulness. But it is extremely rare that two different 
examiners agree about the exact limit of the relative dulness of the 
heart, and for this reason there are great difficulties in giving instruc- 
tion on this point. 

It demands, therefore, much practice, uniformity of method of 
instruction, agreement in the perception of sound and of the resist- 
ance, rightly to estimate the relative dulness of the heart. But on 
account of the imperfectness with which the absolute dulness of the 
heart is determined it is important to give attention and pains to the 
relative. 

How different individual examiners are in regard to this point may 
be learned from the fact that some — as, for example, Reiss — think that 
it is possible to produce by strong percussion the projection of the 
anatomical figure of the heart upon the thorax. In our opinion, how- 



l8o SPECIAL DIAGNOSIS. 

ever, that is much too strong a statement, except with regard to indi- 
vidual cases of very delicate thorax. 

According to Weil, the line of relative heart-dulness is as follows 
(see Fig. 56) : It begins above at the lower border of the third rib, con- 
tinues in a curve downward toward the left, within the mammillary 
line. In rare cases, especially in fat persons and those with a short 
sternum, there is also a relative dulness at the right of the absolute 
dulness, which is Hmited by the lower end of the sternum. In children 
the relative dulness begins at the upper border of the third rib, even in 
the second intercostal space ; it extends somewhat beyond the left 
mammillary line, and is also constantly present on the right, and, 
indeed, reaches even beyond the right side of the sternum. 

Opinion is divided regarding Ebstein's newer method of determin- 
ing by direct palpatory percussion tlie resistance of the heart as the true 
image of the exact size of the heart. Indeed, Eichhorst is the only one 
who warmly espouses the idea. It seems to me that there is no doubt 
of its use in many cases — that is to say, in those with delicate thorax 
having thin covering of flesh. At the same time, I cannot recommend 
it as a subject for instruction to others, since it is liable to give rise to 
many mistakes, and in my opinion it is very difficult to learn. 

3. Method of Percussing the Heart. — We percuss strongly on both 
sides close to the sternum, going downward, and note the upper 
boundary of relative heart-dulness ; then we percuss hghtly the upper 
boundary of absolute heart-dulness ; next we percuss upon the outer 
ends of radii drawn from the middle of what is thought to be an area of 
absolute dulness (first the one obliquely upward to the right, then from 
the right, always beginning beyond the sternum ; then on the left 
obliquely upward ; lastly, from the left), always strongly at first to 
determine a possible relative dulness, then lightly for the absolute. At 
first we percuss at longer intervening spaces, of at least ij- centimeters, 
and, when a difference of resonance is found, then at short intervals of 
space over the particular region. In Fig. 56 the Hnes and the direc- 
tions in which we ought to percuss are designated by arrows. 

For ascertaining the size of the heart in difficult cases, particularly 
if the heart is overlaid by emphysematous lung, Gumprecht has lately 
recommended to percuss while the patient bends forward. He found 
that in this position the area of dulness became larger, more intense, 
and more resistant. The boundaries ascertained in this way, in gen- 
eral, were as follows : the fourth rib, the left edge of the sternum, the 
left mammillary line ; in enlargement of the heart the dulness extended 
over a larger area Avith the patient in the forward position, even if it 
was diminished when lying upon his back. 

Enlargement of the Area of Heart-dulness. — Generally, 
relative dulness and absolute dulness exist in about equal propor- 
tions, but now and then the relative may be very small. Always in 
enlargement of the right side of the heart, and sometimes in enlarge- 
ment of the left side, relative dulness toward the right is increased as 
compared with the absolute. 

Heart-dulness is increased — 

I. In hypertrophy aiid dilatation of the Jieart. If of the right ven- 
tricle, the dulness spreads toward the right, sometimes also slightly 



EXAMINATION OF THE CIRCULATORY APPARATUS. l8l 

toward the left, the whole involving a half-circle. If the left ventricle 
is changed, the increased dulness is toward the left and downward, not 
infrequently also upward, but scarcely any, or at most very little, toward 
the right.^ 

2. In dilatation of the heart (weak heart). This causes the pre- 
viously existing dulness, it may be of a normal heart or of one that 
was already hypertrophied, to spread out on both sides. (For distin- 
guishing from hypertrophy, see *' Apex-beat " and " Radial Pulse.") 

3. Fluid in the pericardiiun {^pericarditis exudativa and hydroperi- 
cardiuni). Generally, this causes the dulness to enlarge, at first upward 
and then to the right and left. Not infrequently the area of dulness 
has a three-cornered shape — one point above close to, and on the left of, 
the sternum, one below on the other side of the sternum, and one on the 
left, also below, on the outer side of the mammillary line ; the relative 
dulness is generally very small. If the exudation is very large, the 
lung surrounding it is generally retracted, and hence around the dul- 
ness there is a border of tympanitic resonance. In sitting up the area 
of dulness is greater than when lying down, and when bending forward 
still greater than in the sitting posture, because there is a change in the 
extent of area which is parietal. 

Regarding the apex-beat in pericarditis, see page 174: in the latter 
disease it is often deeper and not on the left border of the dulness, as 
in enlarged heart, but farther toward the right, and generally within 
the mammillary Hne (a not unimportant point in differential diagnosis). 
The pulse ^ is often important. 

4. When the heai^t is normal, but is to a greater extent parietal on 
account of retraction of the lung. In this case the mobility of the 
border of the lungs in deep breathing is completely wanting. The 
apex-beat may be normal, but by simultaneous displacement it is 
farther to the left. 

5. Apparent enlargement of the heart is noticed if anywhere in its 
neighborhood there is a diseased condition which causes absolute dul- 
ness. Of this kind we may name thickening of the lungs, of the 
pleura, of the mediastinum, and especially aneurysm. It is almost 
impossible to mark the boundary between the heart and such patho- 
logical structures, since we are denied the aid of percussion ; on the 
other hand, an approximate determination may often be attained during 
auscultation by the appearances of motion (apex-beat, etc.), and some- 
times by the vocal fremitus. 

Pulsating affections give especial difficulty, as aneurysm and the 
empyema pulsans previously mentioned. Here the object is sometimes 
attained by repeated examinations. For distinguishing empyema 
pulsans from aneurysm, see the latter. 

Diminution or I^oss of Heart-dulness. — This takes place — 
I. In emphysema of the lungs. It affects the parietal conditions of 
the heart, whether it is normal or enlarged. If the heart is normal, 
there is considerable diminution of the area of dulness, even, possibly, 
to its entire disappearance. If the heart is, at the same time, enlarged 
(as, as has already been mentioned, it generally is in consequence of the 

^ Regarding a small independent dulness which is sometimes found on the right near 
the upper end of the sternum, see Aorta, p. 219. ^ See Pulse. 



1 82 SPECIAL DIAGNOSIS. 

emphysema, which causes hypertrophy of the right ventricle), the 
emphysema makes the dulness smaller than it would be with a heart 
of the same size and normal lungs. Hence, when there is emphysema 
we must make some addition to the extent of the dulness we are able 
to map out before we form a judgment regarding the heart. A normal 
area of heart-dulness, with the existence of a marked emphysema, 
indicates considerable hypertrophy of the heart if there is no adhe- 
sion of the borders of the lungs ; hence we must notice their active 
mobility. 

2. In piieiunopericardiuni entrance of air into the pericardium, 
either from without by an external injury or from within by perforation 
of the esophagus, stomach, or intestine, we may have the condition of 
pneumothorax. There is then tympanitic or abnormally loud and deep 
resonance in the neighborhood of the heart (also metallic heart-sound); 
finally, very rarely in emphysema of the mediastinum} 

Displacement (Dislocation) of the Heart-dulness. — This, of 
course, arises from displacement of the heart, as has been mentioned 
when speaking of the apex-beat ; but in this case, for various reasons, 
percussion is generally an imperfect means of determining such change. 
For one thing, it often happens that the condition which causes the 
dislocation itself presents dulness, which invades the region of heart- 
dulness.^ This is the case when shrinking of the pleura or lungs 
distorts the heart. Again, it is usually especially difficult to determine 
the location of the heart by percussion if there exists a vicarious 
emphysema on the left side simultaneously with considerable shrinking 
on the right. In this case the heart is sometimes moved over to the 
middle of the thorax {inesocardia). 

Still further, the extent to which the heart is parietal is frequently 
changed by dislocation : thus, when the diaphragm stands very high 
the heart is pushed upward, usually causing an increased area of dul- 
ness, since the heart is then more flat against the chest than is normal. 

If there is an apex-beat in such cases, it is a very sure sign ; but often 
it is necessary to employ auscultation to aid in establishing by the loca- 
tion of the greatest intensity of sound, at least approximatively, the 
position of the heart. 

Auscultation of the Heart. 

Methods and Normal Condition. — Methods. — Ordinarily we 
are to auscultate the heart exclusively by the stethoscope. After long 
practice and experience the examiner miay think it advisable to compare 
what he hears with the stethoscope in individual cases — as, for instance, 
in pericarditis — with the results of direct auscultation ; but these are 
exceptions. The very urgent reason for the use of the stethoscope is 
that by it we are able to distinguish as sharply as it is possible to do 
the impressions of sound which come from the different points, so as 
to be able to refer every sign to its proper place of origin. 

First of all, we are to examine the patient when he is in the greatest 
possible quietude of body and mind : in some cases we may then, after 
we have begun, find it advantageous to increase the activity of the 

^ See p. 50. 2 ggg above, p. 181, under 5. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 183 

heart by having the patient make a certain amount of exertion (as by 
sitting up in bed several times in succession or moving about), since 
we can thus sometimes obtain certain signs clearer. This will be 
referred to from time to time. The position of the patient during the 
examination will, in general, be the same as for percussion, already 
referred to. However, we often hear much plainer in the upright 
position, and hence in doubtful cases auscultation in this position 
is not to be neglected. 

More than anywhere else, in auscultation of the heart it is necessary 
to examine several times. The rapidity and strength of the heart's 
action and possible extraneous sounds have a great influence upon the 
distinctness of what is heard. In severe diseases of the heart, especially 
with heart-failure from different causes which will be mentioned, the 
impression is generally so confused that no physician of experience will 
pronounce a definite opinion until, by appropriate treatment, the heart 
has been restored to a degree of strength. 

Normal Condition, — Over the whole region of the heart and for a 
certain distance beyond it we hear, corresponding with each pulsation 
of the heart, two " tones : " one coincides with the ventricular con- 
traction, the ''systolic,'' the ''first'' tone; and one, which is heard not 
exactly, but still approximately, at the beginning of the diastole, the 
" diastolic," the " second," tone. Corresponding with the greater dura- 
tion of the diastole, the pause between the second and the following first 
tone is always greater than that between the first and second. 
The rhythm in general is as represented here : 



Syst. Diast. Syst. Diast. Syst. Diast. Syst. Diast. 

The apex-beat coincides, to a certain extent, in time with the systolic 
sound, and likewise, as we can directly observe, with the pulse in the 
common carotid in the neck. But the pulse of the peripheral arteries 
occurs noticeably later, so that the radial pulse is felt between the first 
and second sounds of the heart. 

The expression " tones " is not to be taken in a strictly acoustic 
sense. In reality, it is a short, sharply-defined noise which only 
approaches a tone. But the term is not so inappropriately selected, 
as every one must be impressed who compares these phenomena of 
sounds with the peculiar heart-sounds to be spoken of hereafter. 

Both of these heart-sounds, the first and second, can be heard over 
the whole region of the heart, but at different points they are of different 
nature and origin, as is partly declared by the character of their tone. 
According to the view now almost universally held, a part of each 
sound has its origin in each of the four portions of the heart, and hence 
is in all eight-fold '} 

I. The sudden tension and closure of the mitral and tricuspid 

^ A short time ago Geigel returned to the opinion formerly held, according to which 
there are only four heart-sounds, and that on account of new considerations this idea is 
worthy of notice. As we have only very recently seen Geigel's explanation, we must sus- 
pend judgment on this question, and hence, for the present, adhere to the opinion already 
expressed. 



1 84 SPECIAL DIAGNOSIS. 

valves causes a systolic sound, which naturally is most distinctly heard 
in the neighborhood of these valves or over the ventricles. 

2. The closure of the semilunar aortic and pulmonary valves causes 
a diastoHc flapping tone, heard most distinctly over those valves or in 
their neighborhood. 

3. The sudden contraction of the ventricle causes a dull systoHc 
sound of short duration. 

4. The sudden filling of the conus arteriosus^ aortic and pulmonary, 
in consequence of the motion of the blood, or, more probably, of the 
sudden tension of the walls of these vessels, causes a short, somewhat 
ringing sound. 

Although after the careful investigations of Krehl one might be 
inclined to consider the first ventricle-sound as only a muscle-sound, it 
seems to us that it is impossible to entirely exclude the auriculo- 
ventricular valves and their tendinous fibers from a participation in the 
production of the first sound. It is difficult to comprehend how the 
undoubtedly sudden closure of these valves and the just as sudden 
stretching of their tendon-fibers should take place without producing 
some sound ; but also the weakening of the first sound, even to entire 
disappearance, which happens in insufficiency of the mitral valve, 
indicates that the closing of the auriculo-ventricular valves participates 
in causing the first sound. 

Thus, we see that the valves have a very essential part in the pro- 
duction of the heart-sound ; and since, as has already been remarked in 
the "Preliminary Observations" [page 167], the heart-sounds arising 
in certain circumstances are only connected with the valves or the 
different openings, these are the chief consideration in auscultation. 
Hence we have chiefly to attend to the auscultation of the mitral 
valve, the mitral orifice, the aortic valve, the aortic orifice, etc. 

Hence it follows that we always first listen at those four points of 
the chest which lie nearest to these valves. But experience has shown 
that for two of them this is not the best method, as is easily under- 
stood from the anatomical relations. 

We cannot auscultate the aortic valves at the point of the chest 
which lies nearest to them, since they are obliquely behind the pulmo- 
nary valves, and at that point the sound which comes from the pulmo- 
nary artery and its valves predominates ; hence we must auscultate at 
the beginning of the aorta ; and likewise we do not ordinarily hear the 
mitral sounds most distinctly at the point where the valve is located, 
since a layer of lung there covers the heart, and also because the right 
ventricle lies in front of the left, but we hear it better at the apex of the 
heart. The points of election for auscultating the heart are as follows 
(compare Fig. 57) : 

1 ra va ve, i ^ ^^ ^^ ^^ heart. 

Lett auriculo-ventncular openmg, J ^ 

Tricuspid valve, 1 ..i, 4. 

-r,.,^^., ^-1 • )■ over the sternum. 

Right auriculo-ventncular opening, J 

Aortic semilunar (ost. aort.) : second intercostal space, right of 

sternum, and for aortic insufficiency the middle of the sternum itself, 

and likewise the fourth intercostal space on the left side close to the 

sternum. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 1 85 

Pulm, semilunar (ost. pulm.) : second intercostal space, left of 
sternum. 

The accompanying figure exhibits the situation of the openings and 
the points where they may be best auscultated. We see that the 
auscultation-points of the mitral and aortic valves are so related to the 
respective openings that they lie downward from them with reference 
to the normal course of the blood-current. 




Fig. 57. — The anatomical situation and the points for auscultating the valves of the heart 
and its orifices. The crosses indicate the anatomical situation, but the black points and lines 
the places to auscultate. The small letters show the location of the valves, the large ones the 
points for auscultating : a A = the aorta ; mM= mitral valve ; /jP = the pulmonary orifice ; tT= 
tricuspid. 

The " sounds " that can be heard in health at the four points men- 
tioned correspond with the occurrence of the sounds just referred to in 
the following way : 

Apex of the heart {initral orifice) : 

1st sound: Closure of the mitral valves and ventricular contrac- 
tion. 
2d sound : Prolonged aortic second sound (closure of aortic 
valve). 
Under the sternum (tricuspid orifice^ : 

1st sound: Closure of the tricuspid valves and ventricular con- 
traction. 
2d sound : Prolonged pulmonary second sound. 
Second intercostal space, right or left {aorta, pulmonary art) : 

1st sound: sudden filling of the beginning of the aorta, of the 
pulmonary artery, and continuation of the first ventricular 
sound. 
2d sound : closure of the semilunar valves of the aorta or of the 
pulmonary artery. 



i86 



SPECIAL DIAGNOSIS. 



Thus, the first sound is a mixed one, composed of muscle, valve, or 
also of vessel-sound ; it is dull and somewhat prolonged. The second 
sound is throughout wholly from the semilunar valves; it is short, 
flapping. Hence I represent the first by a dash, the second by a short 
curved line. The heart's action is hence represented in the following way : 




SI D2 S D S D S 

iS = systole. 2 d_ diastole. 

Fig. 58^. — Representation of normal heart-sounds. 

and since we hear the second sound over the ventricle only as con- 
ducted from above against the current of blood, over the ventricle it is 
very light ; hence the accent at the apex and [over the sternum, i. e.! 
under the sternum is represented as follows : 




In auscultating, however, at the mouth of the arteries we hear the 
second sound at the place of its origin ; it is here louder, and indeed 



either 



or 



L / 1 / / 
1 / /• / 

. 1 _ , 1 .J _ 


3 



D 



S 



D 



S D 

Fig. 59. 
3 This representation departs from the habit of authors, who draw the comparison with 
the trochaic and iambic foot, and this does violence to the length of the sounds merely for 
the sake of making the comparison. I maintain that the above representation is more in 
accordance with the facts. 



louder than the first, and hence the accent is at the base of the heart : 
according as the first sound is like the ventricular sound or not. 

Differences or Variations within Normal Limits. — The absolute 
strength of the heart-sounds varies very much in persons in health. 
It depends upon the elasticity and delicacy of the thorax : children 
and persons with delicate thorax generally have loud heart-sounds ; 
with the former, they are widely conducted by the lungs, and this 
for the same reason that with them the breathing-sound is sharper.^ 
Further, the thickness of the covering of the chest has its effect: 
large mammae, thick layer of fat, weaken the sounds. Temporary 

^ See this. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 1 8/ 

excitement of the heart may increase the sounds so very much that 
even an experienced person may be tempted to suppose that they are 
increased by pathological conditions. 

The tone of the heart-sounds also varies : with many the first sound 
as well as the second is more " tone-Hke," with others less so. Espe- 
cially variable are the first sounds — sometimes shorter, sometimes 
longer, noise-like, " impure ; " further, sometimes very deep and not 
clear, " dull." 

The first sound of the heart (much more rarely the second) may 
even in health be doubled : 




s D s D .s D 

Fig. 6o. — Normal first sound doubled. 

This is generally only at the end of expiration and the beginning of 
inspiration, probably disturbed by the ventricles not contracting syn- 
chronously (see also under Pathological Doubling). 

Regarding the measurement of the intensity of the heart-sounds, 
see below. 

Pathological Changes in the Heart-sounds/ — General 
strengthening of the sounds causes one to infer that there is increased 
activity of the heart : this may occur, as above indicated regarding 
healthy persons,^ but to a still higher degree from temporary excitement 
in nervous disease of the heart, and also in Basedow's disease ; it is 
also a frequent accompaniment of fever ; this strengthening then indi- 
cates increased work of the heart-muscle, without the heart-muscle 
being necessarily hypertrophied. 

Furthermore, in a normal anatomical condition of the heart-muscle 
the sounds may be strengthened if a healthy heart lies free in an abnor- 
mally large space, as in shrinking of the lung. But it must be observed 
that here there is occasionally hypertrophy of the right ventricle. Also 
consolidation of the lungs in the neighborhood of the heart causes the 
heart-sounds to be abnormally loud. Finally, a strengthened and 
flapping character of the heart-sounds is not infrequent in anemia, and 
particularly in chlorosis. 

To these cases of simple strengthening of the heart-sounds others 
stand in opposition, where the phenomenon is combined with the signs 
of hypertrophy of one or both ventricles, and therefore the question of 
hypertrophy of a ventricle must be carefully considered in each case of 
strengthened heart-sounds. Strengthened heart-sounds are, as a matter 
of course, heard over a larger area beyond the heart than normal. They 
may be heard over the whole thorax. However, such more extended 
perception of heart-sounds may be due to condensation of the lungs 
(pneumonia, chronic contracting phthisis). 

It is difficult to measure exactly the strength of the sounds of the 
heart. Recently a very ingenious method has been proposed by H. 

^ It is recommended to arrange in a schedule the pathological conditions of the heart 
revealed by auscultation, and likewise those discovered by percussion. 
^ See preceding page. 



1 88 SPECIAL DIAGNOSIS. 

Vierordt. Its significance will be greatly affected by the changing dead- 
ening effect of the chest- wall and its covering, also of the lungs. It 
is interesting to note that normally the mitral first sound is the loudest 
and the aortic first sound the softest. Dull sounds which, by the usual 
mode of auscultation, the ear is accustomed to consider light, by this 
method sometimes manifest themselves as louder, hke flapping, although 
to the ear the latter sound more intense. 

Strengthening of Separate Sounds. — Strengthening of a second sound 
(more emphatic closure of the semilunar valves), if persistent, is a very 
sure sign of hypertrophy of the corresponding ventricle.^ Only we 
must not consider a slight emphasis of the aortic or pulmonary second 
sound as a pathological strengthening.^ Abnormally strong, accentuated 
ptdmonary second sound is thus a very important sign of hypertrophy of 
the right ventricle, and it is the more important since in this condition 
percussion is often doubtful. Strengthened aortic second sound, espe- 
cially in sclerosis of the aorta, becomes slightly sonorous, ringing. In 
hypertrophy of the left ventricle fi-om insufficiency of the aortic valves 
accentuation is wanting, because in the main the second sound is want- 
ing, since the valves do not close. 

This accentuation of the second sound immediately disappears when 
the heart becomes weak, when heart-failure takes place. The disap- 
pearance of the accentuation of the pulmonary second sound is there- 
fore of especial diagnostic value, since we have no other direct sign of 
commencing failure of the right ventricle. If there occurs a relative 
tricuspid insufficiency from a high degree of weakness and dilatation of 
the right ventricle,^ then the pulmonary second sound almost entirely 
fails, since the blood now has an outlet upon both sides — backward 
through the ostium venosum and forward into the pulmonary artery, 
and thus the pulmonary pressure falls off very greatly. 

In making his observations in a case of disease of the heart the 
importance of the second pulmonary sound cannot be too strongly 
impressed upon the beginner : it is a measure of the activity of the 
right ventricle, as the pulse is of the work of the left. 

Not infrequently both pidmonary sounds (much less frequently both 
aortic sounds) are strengthened by the base of the heart being in con- 
tact with the chest-wall when there is shrinking of the lungs. An 
accented pulmonary second sound from hypertrophy of the right ven- 
tricle may be thus/^// as a diastolic stroke in the left second intercostal 
space. Also in mitral insufficiency with hypertrophy of the left ven- 
tricle and shrinking of the lung an aortic second sound may h^ felt 
in the right second intercostal space. 

Pathological strengthening and flapping character of the first sound 
at the apex are so frequently occurrences in mitral stenosis that to the 
experienced observer they have diagnostic value. The phenomenon 
is ordinarily explained as being a consequence of diminished filling of 
the left ventricle which follows from the lessened size of the orifice by 
which it is filled ; the segments of the mitral valve at the end of the 
diastole are still very lax, and so come together with more energy at 

^ For the conditions which lead to hypertrophy of a ventricle, see Preliminaiy Remarks, 
p. 167. 

2 See p. 186. ^ See Preliminary Remarks, p. 167. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 1 89 

the beginning of the systole. This explanation does not appear to us 
to be wholly acceptable. 

Weakness of all the sounds of the heart (more inclined to concern the 
second sound) occurs in all cases of iveak heart, as takes place in hearts 
previously sound in consequence of over-exertion, severe hemorrhages, 
carbonic-acid poisoning, or any kind of interference with breathing,^ any 
other kind of poison, as heart-poison in acute febrile diseases ; finally, 
in central or peripheral paralysis of the vagus, as follows disease of the 
heart-muscle, or as generally at last from some cause or other over- 
takes an hypertrophied heart. 

Hypertrophy of one division of the heart is, as referred to in the 
Preliminary Remarks,^ generally " compensatory " — that is, it is said to 
accompany any obstruction of the circulation. If a hypertrophic heart 
can no longer meet the demands made upon it, we then use the term 
" incoinpe7tsation!' Then heart-sounds that in part were previously 
strengthened at first become about normal, and then become weaker 
than normal. 

Moreover, when an emphysematous lung forms a layer over the 
heart, the heart-sounds are found to be persistently weakened, even to 
marked indistinctness, and this involves also the pulmonary second 
sound, which in emphysema is strengthened. This weakening occurs 
with large pericardial exudations or Jiydropericardium ; more rarely 
from a tumor or pletiral exudation pressing against the heart. 

Weakening of Individual Sounds. — If there is an " organic heart- 
murmur, ^ then the sound with which it occurs or at which it ceases 
becomes either weakened or indistinct, or it is entirely wanting, so that 
the "murmur" takes the place of the sound. But also with cer- 
tain valvular defects there occurs weakening of other sounds : of the 
aortic second sound in mitral stenosis, in consequence of which the left 
ventricle has only a little blood to throw into the aorta ; * weakening 
of the same aortic second sound in steatosis of the aorta ; also the pulmo- 
nary second sound in stenosis of the ptdmonaiy artery, as a consequence 
of those valves being less free in their action. Not without diagnostic 
value, also, is a high degree of weakening of the first sound at the apex 
m aortic insufficiency. This is explained by the reflux from the aorta, 
with the normal afflux from the auricle, filling the ventricle abnormally 
full : it becomes dilated, and thus the tips of the mitral valves, even 
before the beginning of the systole, are somewhat pushed up. When 
the systole takes place there is then only a moderate increase in its 
tension. Moreover, in aortic insufficiency, over the aorta the first 
sound is often weak and very impure, without other contemporaneous 
signs of aortic stenosis being present.^ 

Alteration in the rhythm of the heart-sounds is observed as follows : 
The pause between the first and second sound becomes of the same 
length as that between the second and first (systole = diastole), and at 
the same time they equal each other also in character and loudness. 
The action of the heart is similar to the tick-tack of a watch, and if, as 
is frequently the case, tachycardia exists at the same time, the whole 

^ See this. 2 ggg Preliminary Remarks, p. 167. 

'^ See p. [191 f ]. * See Preliminary Remarks, p. [168 ff]. 

5 See section on Heart-murmurs and Pulse. 



go 



SPECIAL DIAGNOSIS. 



movement reminds one of the fetal heart-sounds (embryocardia, pendu- 
lum-rhythm). Whether with or without tachycardia, the phenomenon 
is very suspicious of commencing weakness of the heart. We have 
observed it particularly in the diphtheria-heart and in chronic myo- 
carditis as a forerunner of the gallop rhythm. 

Divided or Do2ible Heart-sounds. — These, as we have seen above, 
are ordinarily without significance if the condition otherwise is one of 
health [see page 187]. They occur also in pathological conditions, and 
are then of diagnostic meaning. We bring together here (Fig. 61) the 
cases in which, instead of two heart-sounds, we hear three, without 
sharply separating between " divided " and " doubled " sounds. 

Division of the second sound at the apex occurs in mitral stenosis. 
It may conceal a diastolic sound, which, with the patient in the up- 



Divided : 




Doubled 



S D S 

Fig. 61. — Different kinds of division and doubling of the heart-sounds. 

right position and heart excited, sometimes can only be distinctly 
heard by placing the stethoscope at the outer left end of the apex-beat. 
We may especially refer a divided second sound at the apex, accord- 
ing to my experience, to mitral stenosis, in case there are, besides, 
undoubted signs of mitral insufficiency; and if at the same time the 
pulse is too small for a compensated mitral insufficiency, an incompen- 
sation is thereby excluded. 

Further, a divided second sound is heard in pericarditis adhcesiva 
and systolic retraction of the apex-beat. (Friedreich's explanation of 
the phenomenon may be doubted.) 

Finally, here belongs the gallop rhythm, sometimes : 



or also : 



s s s 



s s 

Fig. 62. — Gallop rhythm. 



that is, three similar short ringing sounds, of which either the second 
or third has an accent, but in many cases neither has an accent. This 



EXAMINATION OF THE CIRCULATORY APPARATUS. IQI 

gallop rhythm may, but quite exceptionally, be observed in health with 
excited action (I have seen several cases). It is also observed in em- 
physema, contracted kidney, arterial sclerosis, heart-disease with slight 
incompensation. But it generally indicates severe, often fatal, heart- 
failure, and especially in infectious diseases. It is particularly frequent 
in children ; it may here — for example, in diphtheria — be the first sign 
of beginning paralysis of the heart, even before the pulse becomes 
markedly quickened. In my opinion the gallop rhythm may be 
explained in the same way as the divided sound, the ventricles not 
contracting at the same time. This question will be variously answered 
by different authors. 

Metallic Heart-sounds. — They come from the resonance of a large 
smooth-walled layer of air close over the heart, as is the case in 
pneumopericardium, not infrequently in pneumothorax, and in indi- 
vidual cases of large cavity in the lung with smooth walls which lies 
close to the heart. Intestinal or peritoneal meteorism'^ or a very much 
inflated stomach may sometimes cause metallic heart-sounds. 

In pneumopericardium, also in cases of inflation of the stomach 
with gas, if the action of the heart is very strong or excited, the 
sounds may be so loud that the first, or even the first and second, 
can be heard at a distance. 

Organic Endocardial Heart-murmurs. — By endocardial heart- 
murmurs, as the name implies, we understand murmurs arising within 
the heart in distinction from those arising in the pericardium. Endo- 
cardial murmurs are again distinguished as organic and inorganic 
according as they are dependent upon anatomical changes or not. We 
now consider the former. 

Oi'ganic heart-murmurs are caused by stenosis of the openings, 
or by imperfect closure of the valves or insufficiency, both the ordinary 
and the relative insufficiency of the valves. They furnish us with an 
important means of recognizing the so-called valvular defects. 

If fluid is flowing through a tube which suddenly at a certain point 
is contracted, from this stenosis eddies arise in the current below 
that point, and these eddies will cause murmurs. If the fluid flows 
very rapidly, the eddies and their sounds are increased. Normally, 
the blood passes through the openings of the heart without sound, 
since there is no notable narrowing of the channel of the blood; but if 
an opening is narrowed, then eddies and sounds are produced, and so 
much the more markedly if there is compensation, when the blood 
from the section of the heart lying behind the narrowed opening is 
driven with much greater rapidity than normal through the narrowed 
opening.^ 

Such a murmur will be heard at the moment when normally the 
blood passes through that opening ; that is, at the systole if an arterial 
opening is narrowed ; at the diastole if a venous opening is affected 
(auriculo-ventricular). 

But insufficiency of the valves produce murmurs which are to be 
explained in the following way : The effect of insufficiency is such 
that the blood, which, in the preceding stage of the heart's action, 
passes through the affected opening, in the following stage, in which 

^ See both of these. ^ See Preliminary Remarks, p. 1 68. 



192 SPECIAL DIAGNOSIS. 

the valves of that orifice would have closed, partly flows back ; it 
likewise flows against the blood normally flowing into the cavity, and 
rebounds with it ; thus eddies arise and also a murmur. The intensity 
of this murmur depends, in the first place, upon the degree of insuf- 
ficiency, and, again, very materially varies with the strength of the 
heart's action ; for the greater this is the more marked is the difference 
in pressure and the more violent the backward current which it causes. 

Likewise, there occurs the miunnur of insufficiency in that stage of 
the heart's action in which the affected valves ought normally to close ; 
that is, at the arterial openings with the diastole, and at the venous 
openings with the systole. 

Moreover, it appears to me to be unquestionable that, in the great 
majority of cases of insufficiency, the murmur is increased by the simul- 
taneous occurrence of a murmur from stenosis ; for the reflux current 
of blood certainly flows through a narrowed opening if the insufficiency 
is not greater than it usually is. I also think that, in connection with 
this, in cases of severe aortic insufficiency (N. B., with full compensa- 
tion), we find the diastolic murmur especially soft. (See further regard- 
ing this the following, upon the influences that affect the loudness and 
character of the heart-murmurs.) 

Localization of the Murmurs. — The next diagnostic point of impor- 
tance is that, from the location in the region of the heart where a mur- 
mur can be heard most distinctly or where it is loudest, we' can 
determine whence it arises — that is, at which opening the valves are 
diseased. The auscultation-points already mentioned, empirically found, 
serve here as points of departure. We listen — 

At the apex of the heart — that is to say, at the point of the apex- 
beat — for the mitral valve, the left venous opening. 

Over the lozver part of the sternum — for the tricuspid valve, the right 
venous opening. 

In the rigJit second intercostal space, close to the sternum — for the 
[aortic] opening and the auricular semilunar valves. 

In the left second intercostal space, close to the sternum — for the 
opening [of the pulmonary artery] and the pulmonary semilunar valves. 

But it is to be noticed that the murmur caused by aortic insufficiency 
is, as a rule, not heard in the right second intercostal space, but 
is most distinct over the sternum, sometimes even in the third or 
fourth intercostal space at the left of the sternum ; since it is also 
caused by the backward flow of the blood, it is conducted in the 
direction of the ventricle. Analogously, but only exceptionally, the 
murmur of insufficiency of the mitral valves may be noticed most 
markedly, not at the apex, but on the left of the base of the heart ; 
that is the case when the dilated left auricle, with its appendage, lies 
somewhat forward (Naunyn). 

The murmur of stenosis of the left auriculo-ventricular opening is 
often distinctly heard close to the outer edge of the apex-beat. 

Relation of the Heart-murmurs to the Time of Action of the Heart. — 
It follows from the above discussion that the organic heart-murmurs 
are very closely connected with certain instants of the action of the 
heart, and, further, that they are divided into systolic and diastolic. 
And thus we hear in — 



EXAMINATION OF THE CIRCULATORY APPARATUS. 



193 



Stenosis of the aorta : A systolic murmur in the right second inter- 
costal space. 



s D s 

Fig. 6s, a} 



Aortic insufficiency: A diastolic murmur at the same place, or, 
better, lower down to the left of this, over the sternum.^ 



s D s 
Fig. 63, b. 



Mitral stenosis : A diastolic murmur at the apex, the first sound 
valvular ; or approximately so, if the second sound is heard at all.^ 




s D s 
Fig. 63, c. 



Mitral insufficiency : A systolic murmur at the apex of the heart, 




or. 




Quite analogously, in pulmonary stenosis and tiHcuspid insufficiency 
we hear a systolic murmur, in pulmonary insufficieiicy , and tricuspid 
stenosis a diastolic murmur at the corresponding points.^ Of these 
valvular defects of the right side of the heart the only one frequently 
present is tricuspid insufficiency, and this is relatively much more fre- 
quent (in great weakness of the heart) than insufficiency caused by 
endocarditis. Pulmonary insufficiency and stenosis are almost always 
congenital, and then are very often associated with a permanently open 
foramen ovale!* 

SystoHc murmurs in stenosis of the aorta and insufficiency of the 
mitral valve, and the diastolic murmur from aortic insufficiency gener- 

^ [Figs. 63a, b, c, d, e,f, indicate endocardial heart-murmurs.] ^ 3ee above. 

^ See more exactly below. * See above. ^ Regarding this, see later. 

1.3 





194 SPECIAL DIAGNOSIS. 

ally are directly joined with the sound affected by them ; but these 
sounds are thus always weakened, or the sound completely disappears 
and the murmur takes its place. In such cases the sound may still be 
heard if we remove the ear a short distance from the ear-plate of the 
stethoscope. Probably the weakened sound is not to be referred to 
the valve that is affected, but is conducted so as to be heard elsewhere. 
On the other hand, a peculiar condition commonly belongs to the 
diastolic murmur of mitral stenosis ; it occurs at the end of the diastole 
as a so-called presystolic murmur, or, if it is present at the beginning 
of the diastole, it becomes stronger toward the end ; hence, either — 



or, 



Fig. 63, ^. 

The explanation of this remarkable phenomenon is very simple : 
toward the end of the diastole the auricle contracts and drives the 
blood with greater rapidity through the narrow ostium venosum ; 
hence the strengthening of the eddy and murmur. 

A diastolic aortic murmur may be heard at the apex only as presys- 
tolic, and then, if one does not examine exactly for the other evidence, 
it may be taken for a mitral murmur and be interpreted as a mitral 
stenosis. However, when there are adhesions of the pericardium we 
also occasionally hear a presystolic murmur. 

If a presystolic murmur is very short, it may make the impression 
on the ear of a " tone," and the second sound seems divided. In such 
cases there are difficulties in making a diagnosis.^ 

In most cases a little practice enables one to recognize in what 
period of the action of the heart an endocardial murmur belongs. But 
if there remains the slightest doubt whether a murmur is systolic or 
diastolic, then the examiner must observe the action of the heart by 
palpating at the same time he is auscultating, and this is best done by 
applying a finger to the common carotid in the neck ; here the pulse 
is almost simultaneous with the ventricular systole, and hence demon- 
strates the time of its occurrence. 

We cannot employ the radial pulse, because it is felt too long after 
the systole. When the action of the heart is very irregular, and still 
more when it is very much accelerated, it is very difficult, or it may be 
entirely impossible, to distinguish between systole and diastole. 




D s 

Fig. 63,/. 
1 See p. 190. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 1 95 

Loudness of the E?tdocardial Murmurs. — From what has ah'eady 
been said it is evident that the loudness of the murmur is not alone 
dependent upon the severity of the valvular lesion. It is also a very 
great mistake to draw a conclusion about the degree of the stenosis or 
insufficiency from the loudness of the murmur; regarding this, the 
effects of the valvular lesions upon the heart and circulation, especially 
the pulse (which see), are much more determinative. 

Murmurs are very much affected by the strength of the action of 
the heart ; they are plainly louder when the heart is excited, and hence 
when they are indistinct, if the patient is able to do so, and is not 
harmed by it, he can first bend forward and stretch out a few times, or 
he can sit up and lie down again several times in bed before we aus- 
cultate him. On the contrary, a murmur previously distinct becomes, 
without exception, more feeble if the strength of the heart declines. 
In very marked weakness of heart the murmur may even become 
entirely imperceptible ; hence in disease of the heart the murmurs 
entirely disappear if an unfavorable turn takes place ; also, they disap- 
pear in cases of heart-disease where the patient is overtaken with a 
severe febrile disease. Hence, an exact diagnosis of disease of the 
heart, if the heart is weak, is always uncertain, and often impossible, 
whenever the action of the heart is accelerated.^ Hard (calcareous) or 
rough valves have the effect of strengtliening or sharpening the murmurs 
of stenosis, or, perhaps, also of insufficiency ; also, in individual cases 
the murmur may be changed by the relaxation or rupture of the 
tendinous cords of the valves.^ In other respects the strength of the 
murmurs is dependent upon the same influences as affect the heart- 
sounds.'^ 

In rare cases the heart-murmur is so marked that it may be heard 
at a distance, without laying the ear over the chest. Such murmurs 
may sometimes be perceived by the patient. The murmurs which 
sometimes have this peculiarity are chiefly those which arise at the 
aortic orifice. 

Murmurs differ very much in character : murmurs of insufficiency 
are, as a rule, softer, blowing, and, indeed, the murmur of aortic insuf- 
ficiency manifests itself often by its length and remarkable delicacy (it 
may easily be overlooked), while that of mitral insufficiency usually is 
louder, but not quite so long. Of the murmurs of stenosis, that of the 
aorta is generally loud, " sawing ;" mitral stenosis, on the other hand, 
is almost always very soft, peculiarly rolling or '* flowing," or seeming 
to consist of several very soft sounds. This murmur is sometimes 
imperceptible, even with strong action of the heart. 

Under some circumstances aortic or mitral murmurs of insufficiency 
may be musical ; that is, they contain a sound which approaches a 
distinct, always very high musical, tone. In such cases it has fre- 
quently been found at the autopsy that the suspected cause of this 
phenomenon in such cases was a perforation of the semilunar valve, 
also torn floating shreds of valves, sinewy threads in the lumen of 
the ventricle, floating torn shreds of papillary muscle, etc. These con- 

^ See Relation of Heart- murmurs to the Time of Action of the Heart, p. 194. 
'''.See Character of the Murmurs. ^ See these. 



196 SPECIAL DIAGNOSIS. 

ditions generally furnish no indication as to the particular heart-lesion ; 
it is, therefore, of no value to recognize them during life. In many 
cases, moreover, of which two came under my own observation, it 
happens that at the autopsy nothing is found to explain the occurrence 
of the musical murmurs during life. 

Metallic murmurs occur under the same conditions as metallic 
heart-sounds,^ in general if there is a resonant air-space near to the 
heart. 

Murmurs that may be felt : endocardial whizzing, '' fremissement 
cataire," cat's purring. This occurs generally, but by no means always, 
with murmurs that are distinguished by their loudness. Locally, their 
most distinct perception by touch always corresponds with the loca- 
tions where they are heard most distinctly. We palpate with the hand 
or finger-tips and recognize thus, though only in rare cases, a fine 
whizzing, which is most Hke what we feel when we stroke the back of 
a purring cat. 

In this way, by the aid of palpation, we may prove the existence at 
the apex of systolic and diastolic or presystolic mitral murmurs, and in 
the right second intercostal space of systoHc and diastolic aortic mur- 
murs. Defects of the right heart seldom produce murmurs that can be 
felt. The palpation of endocardial murmurs has so subordinate a value 
that we can never permit ourselves to dispense with auscultation, which 
yields so much sharper and clearer results. 

Transmission of Heart-iyiurmurs. — It is understood that an endo- 
cardial murmur is very often not confined to that spot on the thorax 
where it is auscultated, but will be heard at some distance away from 
it. The conduction takes place especially in the direction of the blood- 
current. Thus an aortic systolic murmur is often heard even over the 
carotid in the neck. On the other hand, the diastolic aortic murmurs 
generally are perceived over the sternum, even louder than in the right 
second intercostal space ; but they are also often to be heard as far 
down as the apex. SystoHc blowing in mitral insufficiency is some- 
times conducted toward the right as well as farther upward. On the 
other hand, diastolic [presystolic] murmur from mitral stenosis is 
always sharply confined to the left border of the heart. An in- 
organic systolic pulmonary murmur which can be heard some dis- 
tance downward from the base of the heart very often disturbs or 
deceives us. 

Combination of Several Murmurs. — This results from the combina- 
tio7i of several valvular defects. It more frequently happens that insuf- 
ficiency of a valve is connected with stenosis of the opening to which 
that valve belongs. Then we hear at a particular spot a murmur with 
each of the two stages of the heart's action. It is more difficult to 
interpret what is heard when the disease affects different openings or 
valves, and especially if there are two murmurs, both of which occur 
with the systole (mitral insufficiency and aortic stenosis), or both in the 
diastole (mitral stenosis and aortic insufficiency). Then it may happen 
that only one valve is supposed to be diseased, and that the second 
murmur which is heard is transmitted from the first. But also a mis- 
take in the opposite direction may be possible — namely, that we assume 
* See Metallic Heart-sounds, p. 191. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 1 97 

that there is a combination of two valvular affections when in fact there 
is only one, as when a murmur of aortic insufficiency which is heard at 
the apex is considered as a new, independent murmur produced by 
mitral stenosis. The differentiation by auscultation is made in two 
ways : I. By the character of the murmur. If one is blowing and the 
other is rough, there certainly are two murmurs ; if both are alike, then 
there may be only one, which is conveyed from the opening where it 
arises to a second opening. Yet it might be that even in this case 
there were two murmurs, with different origin. 2. We auscultate step 
by step from the point where we can hear one to where the other 
exists, as from the apex to the aorta. If the murmur is everywhere 
distinct, only that toward one spot it gradually becomes louder, then it 
arises at this point and is conveyed to another. But if it is lost some- 
where on the way from the apex to the aorta, and is again heard at the 
aorta, then there are two murmurs. 

This procedure may answer the purpose, but it often fails, and in 
such difficult cases auscultation alone cannot decide, but we must take 
a view of the whole picture of the heart and vessels in order to reach 
a diagnosis.^ 

Finally, murmurs that arise in the neighborhood of the heart may 
be mistaken for heart-murmurs. Those that come from the trachea 
and bronchi can easily be excluded by having the patient, if necessary, 
hold the breath. But it is more difficult to discriminate between heart- 
murmurs and those that have their origin in the aorta (especially 
aneurysm).^ 

Inorg-anic, Anemic Murmurs.^ — These are so designated 
because they occur in all forms of anemia, both slight and severe, but 
especially in chlorosis, in all wasting diseases, and also m febrile diseases, 
without there being any disease of the heart or vessels. They serve 
as a sign of anemia ; they generally entirely disappear with the removal 
of this condition. 

In very pronounced cases there are very soft, systolic, blowing 
murmurs, which are heard over the pulmonary artery or lower down 
with indefinite location, or they may even be heard over the apex. But 
not very infrequently such an inorganic murmur is also sharp, even 
very loud,; on the other hand, it is very seldom diastolic; also we may 
almost say that it never is heard over the aorta. Thus the other signs 
of valvular disease are wanting, especially hypertrophy of a ventricle, 
while the pulse gives evidence of anemia, and there are murmurs in 
certain vessels, especially the veins of the neck. 

Sometimes there is at the same time considerable dilatation of the 
heart, as takes place in anemia ; * on the other hand, we have those 
marked dilatations which give rise to murmurs from relative valvidqr 
insufficiency, and which may also exist in severe conditions with which' 
we are not at present concerned. . 

It is very di^cult to explain anemic heart-murmurs. Nothing of 
what has already- been said regarding murmurs seems to us to be 
applicable here : we think, with others, that the nature of the phenom- 
ena differs in different cases, and in many cases we may apply Sahli's 

^ For further on this, see below, 2 Yox further on this, see below. 

^ Synonyms : Accidental Blood-murmurs. * See above. 



198 SPECIAL DIAGNOSIS. 

supposition that venous murmurs from the large veins in the thorax He 
behind these heart-murmurs. 

For distinguishing them from the organic heart-murmurs it is in 
the first place necessary to call to mind what has been mentioned as 
characteristic of anemic murmurs, and then to observe whether there 
are other signs of anemia present. Further, a valvular defect is to be 
excluded by the most careful examination of the heart and pulse. It 
is true that in many cases the phenomena are such that we can only 
obtain a clear idea by long observation, especially remarking whether 
treatment of the anemia removes the murmur. It is very difficult to 
decide that a diastolic murmur is due to anemia. 

The author recalls having seen two cases of pronounced pernicious 
anemia complicated with mitral endocarditis and mitral insufficiency, in 
both of which the differential diagnosis between anemic murmurs and 
the valvular disease mentioned could not be positively established 
during life. In both there existed simultaneously considerable emphy- 
sema which concealed the slight hypertrophy of the left and right 
ventricles. 

Pericardial Murmurs [Friction-sounds]. — The name explains 
the situation of these murmurs. Their nature is the same as pleuritic 
friction-sounds ; they are caused by the friction of the visceral and 
parietal pericardium made by the action of the heart when their oppos- 
ing surfaces rub against one another ; they do this when the surfaces 
are rough, exceptionally even if they are simply unusually dry. 

The relation of the friction-sound to the action of the heart is of 
great importance: it occurs, not in close conjunction with the sounds, 
but between them, either only during the systole or more frequently in 
both stages, but generally louder with the first sound : 




More rarely, tolerably closely before and after the second sound 




S D S D S D 

Fig. 64, h. 



or covering the first sound : 




[Figs. 64, a, b, and c indicate pericardial heart-murmurs.] 



EXAMINATION OF THE CIRCULATORY APPARATUS. 1 99 

Less important than the preceding is it to note that we have near 
to the ear a ringing, short scratching, scraping, shuffling, more rarely 
a creaking, sound, one which with a httle practice is generally easily 
correctly recognized by its acoustic character. It is generally very 
sharply defined as to location, and is most frequently heard at the 
base of the heart, but often farther down at the left of the sternum. 

The rubbing of marked pericardial friction-sounds can be felt by 
applying the hand to the spot. Several special peculiarities of these 
friction-sounds will be mentioned when we treat of Differential Diag- 
nosis. 

Pericardial friction-sounds occur : 

In pericarditis, when the surfaces of the pericardium, where the 
fibrinous exudation exists, rub against each other without becoming 
adherent. Hence, we hear friction-sounds in pericarditis sicca so long 
as it is not adhesive, and in pericarditis exudativa if there is fibrinous 
exudation without enough fluid completely to keep the surfaces of the 
pericardium apart. This is why the friction-sound is generally heard 
at the base of the heart or near to it ; it is not infrequently heard there 
as the first sign, and then often disappears as the exudation increases, 
and it may again return when the exudation diminishes. The disap- 
pearance of a previously existing pericardial friction-sound may depend 
upon one of four causes: i. The complete decline of a pericarditis 
without any sequelae. 2. By the addition of a fluid exudation. 3. By 
adhesion of the pericardial surfaces. 4. From great weakness of the 
heart. It is necessary to ascertain in every case which of these four 
causes is operating. If there is no evidence of the second or the 
fourth, then the first and third must be considered ; and between these 
it is possible to make a differential diagnosis only in very rare cases. 

They also occur in rare cases of tubercidosis of the pericardium 
(which usually results in adhesion), quite exceptionally with fragments 
of fibrinous cords and calcifications in the pericardium, and in abnormal 
dryness of the pericardimn, as in cholera. 

The differential diagnosis between pericardial and endocardial 
murmurs is generally very easy for those who are accustomed to hear 
both sounds, frequently by the character of the pericardial sounds and 
the circumstance that they sound so near the ear. Musical persons 
generally also immediately recognize the difference in time.^ But the 
following may enable us to distinguish between them : 

(a) Very much the most important is the consideration of the whole 
picture of the disease (form of the dulness, apex-beat, sounds, pulse, 
etc.). 

{b) Change of Position. — The pericardial sound almost always 
changes, and much more than the endocardial, with change of position. 

{c) Strong pressure with the stethoscope. If we press exactly at 
the right spot, especially if it be in an intercostal space, sometimes the 
pressure very strikingly increases a pericardial sound, but never an 
endocardial one. But in the majority of cases, even of the former, the 
sounds are not increased by pressure ; hence it is merely confirmatory 
when it exists, but failure to notice it has no meaning. 

(d) Pericardial sounds often change their location, strength, and 

^ See above. 



200 SPECIAL DIAGNOSIS. 

character in a few hours ; they may even very quickly disappear and 
very suddenly return/ Endocardial murmurs are markedly chronic 
and regular. Very exceptionally they come and disappear suddenly 
if they are organic, and only in exceptional cases when due to heart- 
weakness. 

Extra- pericardial Friction-sounds. — The friction-sounds which are 
heard close to the heart, and even over it, and which resemble them 
in sound, may be very easily confounded with the pericardial sounds. 
This extra-pericardial sound is, in the great majority of cases, 2. pleuritic 
friction-sound which is caused by the contact of the pleura with the 
heart, especially at the lingula, and which by the mechanical effect of 
the action of the heart results in thrusts which correspond with the 
movements of the heart. It is distinguished from pericardial friction- 
sound in that it is greatly influenced by the breathing : it is often heard 
only with deep inspiration or, on the contrary, during very superficial 
breathing. In individual cases we hear it as pleuritic friction with 
strong breathing, while with quiet breathing it has the time of peri- 
cardial friction-sound. 

There occurs also a peritoneal friction with peritonitis, involving 
the lower surface of the diaphragm (subphrenic peritonitis), and quite 
exceptionally over the liver. This sound is transmitted by the motion 
of the heart upon the diaphragm as a pseudo-pericardial sound. 

The differential diagnosis of these sounds from pericarditis will de- 
pend upon the other signs of a pleurisy or peritonitis, and with refer- 
ence to pleuro-pericardial friction the effect of the breathing is to be 
considered. Hence the differential diagnosis may here be very diffi- 
cult, because sometimes a pleurisy close to the heart may by contiguity 
awaken a pericarditis. 

Fine crepitations, like those in emphysema of the skin,^ occur in the 
neighborhood of the heart, synchronous with the action of the heart, in 
mediastinal emphysema. 

Metallic pericardial splashing results from fluid and air in the peri- 
cardium (pyopneumocardiumj, exactly as we have succussion-sound 
with hydropneumothorax, only that the succussion is caused by the 
heart itself Moreover, after the analogy of extra-pericardial friction- 
sound, a pseudo-pericardial — in fact, pleuritic — splashing, simultaneous 
with the motions of the heart, occurs with hydropneumothorax, where 
the motions of the heart are communicated to the fluid. This happens 
exceptionally, too, with large cavities which lie close to the heart. 
Finally, it happens that the movements of the heart produce metallic 
resonance or splashing sounds in the stomach. This has been observed 
exceptionally and temporarily in healthy people if the stomach was very 
full. As a permanent phenomenon it has been described in isolated 
cases of coalescence of the pericardium (Riess). Here it is probable 
that the coalescence of the heart with the pericardium, and also the 
eventual adhesion of the pericardium to the upper surface of the dia- 
phragm, may produce a more direct transmission of the beats of the 
heart to the wall of the stomach, or, in turn, to the contents of the 
stomach. 

Exploratory puncture of the heart is only to be undertaken with 

^ See above. ^ See p. 49. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 201 

reference to the performance of puncture, and hence belongs under 
therapeutics. 

EXAMINATION OF THE ARTERIES. 

, Usually we select the radial pulse, which, because of its importance, 
requires a separate and complete consideration. Then we can add to 
this the description of the characters of the other arteries. 

I. The Pulse, its Palpation and Graphic Representation. 

From the commencement of medical study the radial artery has 
been examined where it passes between the styloid process of the 
radius and the tendons of the long flexors of the hand and fingers. 
The examination of the pulse is not a simple thing. It requires much 
practice, and hence it is the more important, in order to be able to 
recognize the differences and peculiarities of different cases, always to 
take the pulse at the same artery ; but it is easy to understand that 
the radial artery is preferable because of its location, and hence it has 
been selected. 

At the same time, it is to be noted that the arteries of the forearm 
not infrequently pursue an abnormal course. The most frequent 
anomaly is of the radial artery, in that it passes across the radius out- 
ward and upward ; or the ulnar artery may be enlarged at the expense 
of the radial. In the latter case, of course, the pulse of the radial is 
small. These anomalies may be on one or both sides. 

Arterial sclerosis usually influences the examination of the pulse to 
a very marked degree, and must therefore not be overlooked. 

Palpation of the Pulse. — The arm being held in an unconstrained 
position, we palpate the radial by making slight pressure upon it with 
the tips of the first and second fingers. Generally the impression is 
threefold : we learn the condition of the artery itself, the general state 
of its ftdness with blood, and its pulsatory dilatation and contraction. 
This latter constitutes the pulse in its narrow sense. 

We study the pulse with reference to its frequency, its rhythm 
(whether the succession of beats is regular or not), and its quality. 
First we consider the normal pulse ; then the pathological departures 
from it with reference to these three points of view. 

1. The Normal Pulse. — \\.?> frequency vaxx^'^ with t\\Q period of life. 
In the newly-born it varies much : when active it is as high as 140 in 
the minute, but during sleep it is 90 to 100. Up to the tenth year it is 
about 90, and at about the sixteenth year it is 76 to 70. It remains at 
about this number in healthy persons till old age, when it sometimes 
increases again to about 80 in the minute. 

There are variations, it is true, from these figures in perfectly healthy 
adults, who may continuously and regularly have a lower pulse, even 
down to 60 (or still lower). Sex makes a slight difference, the female 
average being a few beats more than the male at the same age. 
Moreover, the size of the body has some influence : the average of large 
persons is somewhat less than that of smaller persons, cceteris paribus. 

The daily variations in the frequency of the pulse correspond with 
those of the bodily temperature ; the maximum is generally between 



202 SPECIAL DIAGNOSIS. 

noon and evening, the minimum in the early morning ; the difference 
is generally less than ten, seldom more than twenty, beats. 

Of about the same value is the variation of the pulse with reference 
to the position of the body : its frequency is highest in standing, less 
while sitting, and least while lying down. It varies also with the 
external temperature in case the latter changes considerably from the 
average : the lower the temperature the higher the pulse. 

Meals, especially of food that is rich and of hot dishes and drinks, 
quicken the pulse for one or two hours. Sleep has no essential effect, 
though the pulse rises, and generally considerably for a short time, at 
the moment of waking, even when this is without noticeable excite- 
ment. 

Movement of the body always increases the frequency, under some 
circumstances even till the frequency is doubled. Active deep breath- 
ing increases it. Mental excitement of any kind, as fright, anxiety, joy, 
joyful or painful tension, hkewise quickens the pulse, but very dif- 
ferently in amount in different individuals according to their general 
excitability. 

All the above-mentioned influences manifest themselves with very 
marked variations according to the bodily constitution and the cha- 
racter of the nervous system [temperament]. Pale, delicate persons, 
who are also excitable, show the greatest increase in frequency. Dur- 
ing convalescence merely rising in bed, a little food, joyful or sad 
news, considerably quickens the pulse. In disease this is still more 
the case. 

Method of Observing the Pulse. — After excluding the temporary 
influences that have been mentioned, we count by the second-hand of 
the watch for twenty seconds ; where greater exactness is required, for 
a half or full minute. Sometimes in hospitals the nurses employ small 
sand-glasses ; of course their accuracy must be carefully tested. [In 
England and America these glasses are not used.] Sometimes in sick- 
ness the pulse is so frequent that it cannot be counted. It has been 
recommended, under these circumstances, to try to count every other 
beat, and then to double the result. If the radial pulse cannot be 
felt, or if we suspect that some beats drop out,^ we can then count 
while we auscultate the heart. 

In connection with the employment of temperature-charts we have 
become accustomed to note upon the chart, every time the tempera- 
ture is taken, also the frequency of the pulse and respiration ; thus we 
obtain upon the fever-chart a continuous line representing the pulse, 
which materially aids in forming a judgment of it. (Regarding the 
value of this continued observation of the pulse, see below.) 

The rhythm of the pulse in perfect mental quiet and during quiet 
breathing is in health regular. But mental excitement easily makes 
the pulse somewhat irregular, especially in nervous persons. Again, 
the rhythm of the pulse is changed with many persons during deep 
breathing, especially, too, in nervous persons. Usually at the end of 
expiration and the beginning of inspiration it is quicker, while at the 
height of inspiration and the beginning of expiration it is slower. 

Normally the pulse at the two radials is exactly simultaneous ; the 
^ See under Intermittent Pulse. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 203 

crural pulse is also approximatively simultaneous with the radial. But 
if we compare the radial with the action of the heart, we notice that it 
is always notably later than the corresponding systole. 

Regarding the quality of the pulse : the radial in health has a cer- 
tain general fulness and hardness, and the separate pulse-waves also 
have a certain size, hardness, and form. All these peculiarities ex- 
hibit not inconsiderable variations within the normal. Correct estimate 
of them by palpation is a matter of much careful practice.^ Here it is 
next to be remarked that in the normal pulse equality of its separate 
beats is desirable {equal pulse) ; only quite small, scarcely perceptible 
inequality sometimes occurs, again especially with nervous persons. A 
general symmetrical increase in the hardness of the pulse and enlarge- 
ment of its waves are results of physical exertion, mental excitement, 
etc. — in short, from anything that temporarily quickens the action of 
the heart.^ 

2. Pathological Frequency of the Pulse. — We distinguish a pulsus 
varus (slow, infrequent pulse) and 2, frequent pulse (accelerated pulse). 

Care must be taken not to confound pulsus rarus with pulsus inter- 
mittens, in which the pulse-waves are unequal, and some of them so 
weak that they cannot be felt at all. With some practice pulsus inter- 
mittens is usually easily recognized. In some cases, however, even a 
more practised physician may once in a while be mistaken, as when the 
inequality of the heart-beat, and hence the intermittence, is periodic, so 
that the pauses between the palpable pulses become nearly equal. 
Here belong particularly pulsus bigeniinus and trigeminus alternans. 

In case of doubt auscultation of the heart always at once removes 
the doubt. 

Of late pulsus rarus has frequently been an object of scientific 
investigation (Grob, Riegel). Occasion has even been taken to distin- 
guish it by a particular proof of respect : it has received a name. Re- 
tardation of the pulse, so that the number falls below 60, is called 
bradycardia. This name may be confounded by the hearer with the 
opposite, tachycardia, unless the speaker pronounces very distinctly. 

As a physiological phenomenon /^//y^j- rarus appears only occasion- 
ally ; at least it is extremely rare in the perfectly healthy. In persons 
beyond the thirties it always gives rise to a suspicion of coronary 
sclerosis or of fatty heart, if other phenomena are entirely absent. 

The transition condition to the pathological pulsus rarus is that in 
which it occurs during the puerperium and in the state of starvation. 

Pathological bradycardia is found under very different conditions. 
The cause is partly direct or reflex irritation of the vagus center, prob- 
ably also irritation of the vagus trunk ; partly increase of arterial pres- 
sure by vaso-motor or purely muscular contraction of the peripheral 
arteries ; partly diminution of pressure by loss of blood ; then indirect 
influences on the heart-muscle of substances circulating in the blood 
also come into consideration ; and, finally, anatomical changes of the 
muscular tissue of the heart or of the endocardium. 

Retardation of the pulse is therefore observed — 

I. In individual cases of pathological increase of the work of the 
heart — namely, in acute nephritis, especially the nephritis of scarlet 

^ For particulars regarding the dififer-ent forms of pulse, see p. 208, /i ^ See this. 



204 SPECIAL DIAGNOSIS. 

fever. Hypertrophy of the left ventricle is often included here. But 
the diminished frequency of the pulse is very slight. 

2. In the opposite condition of diminished pressure in the arterial 
system in consequence of JiemorrJiagey and in individual cases of febrile 
diseases ending in fatal collapse. 

3. Sometimes with stenosis ostii aortce ; here the difference is usually 
very slight — about 60 beats. 

4. In disease of the heart-muscle, especially m fatty heart, but also in 
fibroid myocarditis (but here we must be on our guard not to confound 
it with intermittent pulse) ; ^ 48 to 36 beats are here not at all infre- 
quently met with. The lowest number pretended to have been 
observed is 8. 

In acute dilatation of the heart from over-exertion, whether it 
occurs in a diseased heart or one previously sound. 

5. In old age, sometimes without any gross disease of the heart, 
and in marked inanition (from stenosis of esophagus, pylorus, etc.). 
Here, also, the slowing of the pulse may be considerable — even to 48 
or less. 

6. In disease of tJie brain or of the meninges, which results in irrita- 
tion of the vagus center. This may really be only mechanical, from 
increased intracranial pressure (tumors, hemorrliages, Jiydrocephalus) or 
from inflammatory irritation (acute meningitis, especially basilar). The 
slowing is considerable in the majority of cases. 

7. In individual rare cases of irritation of the vagus nerve by com- 
pression (tumors) or by inflammation (abscess) in its neighborhood. 

8. In neurasthenia, hysteria (rare). 

9. In all possible, mostly painful, diseases of the abdominal organs, 
especially in ulcer of the stomach.^ 

10. In the critical decline of fever in acute febrile diseases, possibly 
from the effect of certain products of the fever upon the heart or the 
vagus center, an effect which is only manifest w^hen the quickening 
effect of the high temperature upon the pulse is past.^ It is a con- 
siderable, but quite temporary, slowing. 

11. In Jiepatogenic icterus, from the effect upon the heart of the gall- 
acids circulating in the blood. The pulse is diminished quite frequently 
as low as to 48, sometimes still lower. The slowing disappears, and 
is even followed by acceleration of the pulse, in persistent icterus if 
there develops cachexia, particularly a decrease of heart-power. 

12. In certain intoxications, especially in lead and in acute alcoholic 
poisoning. 

Bradycardia occurs in a pronounced degree, but intermittently, in 
coHc, particularly in lead colic, also in attacks of pain of other kinds, 
especially neuralgias ; finally, in angina pectoris, not only in the so- 
called organic. angina, notably in coronary angina (angina from sclerosis 
of the coronary artery), but also the nervous anginas called vaso-motor 
because produced by a sudden narrowing of the peripheral arteries. 
However, great retardation does not occur in the latter condition, but 
only in angina pectoris organica, especially coronaria. 

Frequent pulse, or tacJiycardia, occurs — 

I. In fever, as its chief manifestation. We recognize a general 

1 See this. 2 Compare bradycardia in colic. See below. ^ See below. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 



20$ 



relation between the elevation of the temperature and quickening of 
the pulse — to every degree of heat above 37° the pulse increases 8 
beats above the normal (Liebermeister) ; but there are very great 



p. T. 



180 41° 



160 40 



140 39 



120 38 



100 37 




P. T. 



160 40° 



140 39 




120 



100 37 



60 35 

Fig. 65. — Diminution of frequency 
of pulse after critical fall of temperature 
in pneumonia. The unbroken line 
represents the temperature-curve, the 
broken one the pulse-curve. 



■Hi 



jg^^mn 



•"wm 



■■■■■■ilVMIfJBIIfai^SHH 

glB8a8tffl?ISS18Ba 

HeHIH 




Fig. 66. — Abdominal typhus in the third to the 
fourth w^eek. The rise in the pulse corresponds 
with the beginning of pneumonia. 



variations from this proportion according to the kind of febrile disease, 
its localization in particular organs, and, further, with the age of the 
patient and the strength of the heart. Thus, in abdominal typhus 
[typhoid fever], so long as it is not accompanied by compHcations, 
there is only a moderate quickening of the pulse; hence, in this disease 
a higher pulse — a pulse of 120, for instance — has a graver meaning 
than, for example, it has in pneumonia. This moderate quickening of 
the pulse peculiar to typhus abdominalis [typhoid fever] is even an aid 
in diagnosis in severe cases, as distinguishing it from acute miliary 
tuberculosis and pyemia, where the pulse is high. It has already been 
mentioned that in meniitgitis there is slowing of the pulse ; when men- 
ingitis is added to a febrile disease, it may lower the pulse, previously 
quickened, to the normal, or may even bring it below the normal. On 
the other hand, during an abdominal typhus [typhoid fever] the addi- 
tion of a complicating pneumonia will, under some circumstances, be 
first noticed by the increased frequency of the pulse (see Fig. 66). 
Febrile diseases with complicating heart-disease usually have a quicker 
pulse than the same diseases when the heart is normal. With children 
the pulse is always very much higher in febrile diseases than with 
adults. 

In the course of febrile diseases the constant observation of the 
frequency of the pulse is of the greatest importance for estimating the 
strength of the heart, and with it the general vigor, or showing the 



206 SPECIAL DIAGNOSIS. 

occurrence of complications, etc.^ It is also to be observed that in 



200 42° 



180 41 



160 40 




200 



80 36 



Fig. 67. — Very rapid action of the 
heart (mitral insufficiency). 




100 37 



80 36 



Fig. 68. — Very rapid action of the 
heart (convalescence from typhus; 
suspicion of mitral insufficiency). 



fever the frequency of the pulse is immediately increased by the least 
exertion or by excitement. 

In general, it is an unfavorable sign when adults have a pulse of 



p. T. 



160 40° 



140 39 




120 38 



100 37 



Fig. 69.— Increased frequency of the pulse in fatal collapse (erysipelas). 



over 120, and the case requires special consideration. But when it 
reaches 140 it is a grave symptom. 

1 On this point, see below. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 20/ 

Frequent pulse also occurs — 

2. In different forms of anemia, especially in chlorosis. 

3. In valvular disease of the heart (except only in stenosis of the 
aorta)/ and also even with complete compensation. 

4. In heart-failure or paralysis. Thus, in the collapse of febrile dis- 
eases (see Fig. 69), where there is a simultaneous fall of the temperature 
and rise of the pulse ; moreover in the arrested compensation of heart- 
disease, and in weakening of the heart in consequence of disease of the 
substance of the heart — more rarely in those cases of heart-weakness 
which complicate an attack of angina pectoris in organic disease of the 
heart. 

5. With central and peripheral paralysis of the vagus. 

6. In certain neuroses : Basedow's disease, traumatic neurosis, ner- 
vous palpitation, functional (nervous, hysterical) angina pectoris, without 
the nature of this phenomenon being clear. 

7. In any condition of anxiety, and with severe pain. 

Here we have mostly to do with a frequency of the pulse which 
develops more or less gradually, lasts a certain time, and disappears 
again gradually. But in a part of the cases mentioned above tachy- 
cardia, and that sometimes of an extremely high degree, comes on in 
attacks — paroxysmal tachycardia, tachy cardie fit} Such attacks are 
seen in the conditions mentioned under 3, 5, and 6. It is remarkable 
that in these attacks there may be missing not only signs of defective 
motive-power of the heart, but also subjective complaints, even if the 
attacks occur in persons with organically diseased hearts ; for instance, 
with valvular defects. 

In some of the conditions named above — /. e. in anemia, in functional 
neuroses, and in slight diseases of the heart — it may happen that the 
frequency of the pulse is normal or only a little increased during rest, 
but is much increased in moderate exertion of the body. 

3. Want of Rhythm of the Pulse. — Instead of the normal equal 
succession of the beats, there may be complete irregularity {arhytJini) ; 
in the most marked degree this is so in mitral stenosis, even when 
there is perfect compensation. Moderate or marked arhythm is very 
frequent in myocarditis (sometimes the inequality of the pulse is here 
tJie only sign). It occurs during the stage of incompensation in all 
cases of heart-defect, and sometimes in all forms of marked heart- 
weakness. Moreover, the inequality of the pulse ^ [irregularity of 
volume] is more important in judging of the weakness of the heart 
than arhythm. 

If in such arhythm there are individual pauses in which no pulse is 
felt, then we speak of '' suspended" pulse, which may be pulsus deficiens 
— that is, the pauses indicate real pauses in the action of the heart ; or 
it maybe a pidsus intermittens : these pauses result from weak contrac- 
tions of the heart, which cannot be felt as far as the radial. We deter- 
mine, in a given case, which of the two kinds of pulse it is by auscul- 
tating the heart. 

But there are other forms of irregularity of pulse in which the 
irregularity of the beats follows a rule : p?ilsus bigemimts, p. trigemi- 
nus (where two or three beats are regular and then follows a longer 

1 See above. ^ Compare Figs. 67 and 68. ^ See this below. 



208 SPECIAL DIAGNOSIS. 

pause). These forms generally indicate moderate weakness of the 
heart. 

Lastly, we must mention an especially frequent form of irregularity 
which stands somewhat between the two last-named forms and com- 
plete irregularity — the pulsus intercidens : after several perfectly regular 
beats, suddenly there is one that follows immediately after the last 
regular one (which is also always weaker), then there generally follows 
a slight pause. Most frequently it indicates considerable weakness of 
heart, and is often the forerunner of severe heart-weakness. It occurs 
in valvular disease and myocarditis. 

In order to determine the succession of pulse-beats it is sometimes 
useful to employ the graphic method.^ 

4. Quality of the Pulse. — As has been already mentioned above, a 
correct judgment of the size and tension of the radial artery and of the 
size and form of the individual waves can only be attained by much 
practice. It is indispensably necessary that there should be acuteness 
of feeling in the examining finger, much experience of what is normal 
and what is pathological, and of the boundaries between the two, which 
cannot be sharply defined in words. The inequality of the examination 
must be taken into consideration, as it is affected by somewhat individual 
differences of the location of the arteries, the difference in the subcu- 
taneous fat, or as affected by arterial sclerosis. The exact examina- 
tion of the pulse may not be possible on account of the abnormal 
course of the radial artery — the most frequent variation being where 
the artery winds around the radius to its dorsal surface above the 
styloid process. 

We distinguish the different forms of pulse according to the follow- 
ing points of view : 

I. According to the size of the pulse : full or empty ^^xA^^, pulsus 
plenus — vacuus ; a not very clear method of designation. It would be 
much more suitable to describe the average fulness of the artery, or, 
still better, its thickness at the moment of its systole — that is, in the 
depression between two pulse-waves. In this sense the pulse is full in 
almost all those cases in which it is large,^ in so far as it depends upon 
work of the heart, which is strong or increased. But it further depends, 
to a certain extent, upon the amount of blood in the system ; a certain 
fulness of the pulse, which in a strong person is not remarkable, in an 
anemic subject indicates a pathological increase in the work of the 
heart. Within certain limits, moreover, the difference in the fulness of 
the pulse is individual, being simply dependent upon the internal 
diameter of the arteries. We are not to confound a full pulse with a 
case where there is thickening of the wall of the artery by arterial 
sclerosis. 

Large and small pidse : pulsus uiagnus — parvus. When the work 
of the heart is simply increased, and still more when there is hyper- 
trophy of the left ventricle, the pulse is large. There is an exception to 
this when we have the two valvular defects in which the left ventricle, 
notwithstanding its hypertrophy, is able to force only a moderate 
quantity of blood into the aorta — aortic stenosis^ and mitral insuf- 
ficiency. The reason for the former is clear ; the explanation of the 

^ See this. ^ 5gg below. ^ See Pulsus Tardus. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 209 

latter is, that with every systole a part of the blood contained in the 
left ventricle flows back into the left auricle. 

Small pulse depends upon diminished work of the heart, upon an 
obstruction between the heart and the aortic system (aortic stenosis, 
aneurysm), and upon marked anemia. It is present in the highest 
degree in mitral stenosis^ since in this condition the left ventricle con- 
tains an abnormally small quantity of blood, and hence it can drive but 
little into the aorta. 

If the pulse is very small, and at the same time very empty, it is 
called thread-like or filiform. The trembling pulse {pulsus tremulus) is 
caused by a moderately full artery, in which the wave is imperceptibly 
small. Both are noticed when the heart is very weak. 

Regular and irregular pulse [as to volume] : pulsus cequalis — in- 
cequalis. As was previously stated, there occur in health insignificant 
irregularities in the individual pulse-waves. A very marked inequality 
is a most important sign of weak heart, more important than the 
irregularity which almost always accompanies it. Only in mitral ste- 
nosis we have a very markedly unequal (and irregular) pulse without 
the heart being really weak. 

Often, too, there exists in a measure a condition between inequality 
and irregularity, as follows : A pulse follows the previous one with a 
shorter pause, then after a longer pause there is one with a stronger 
beat. Especially in pulsus intercidens ^ the between-beat that immedi- 
ately follows a pulse-wave is always small. 

Pulsus alternans is so called when a larger wave alternates with a 
smaller one. At the same time it is generally bigeminous.^ 

We call a pulse pulsus paradoxus which has the peculiarity that in 
deep breathing, toward the end of inspiration, it becomes weaker or is 
once or more times omitted. It is an important sign of pericarditis 
adhcesiva with fibroid mediastino-pericarditis, and it arises from the 
bending or traction of large arterial branches as the thorax is broad- 
ened in the act of inspiration and the diaphragm is pressed down. 

2. We distinguish the form of the pulse-wave as quick or slow, 
pulsus celer — tardus. Here also belongs the pidsus dicrotus. 

In the quick pidse the artery quickly enlarges, and immediately 
becomes narrow with a like quick contraction. But with a slow pidse 
the enlargement and contraction are slower than normal, and the artery 
also lingers in the diastole during a portion of time which a trained 
finger may recognize. With the quick pulse the examiner notices that 
the stroke is very short, while in the latter it is more a pressure in the 
vessel against the palpating finger. 

Every pulsus magnus may exhibit a moderate celerity. Only in 
aortic insufficiency is the pulse decidedly quick. It is a miniature pict- 
ure of the large fluctuations of pressure in the aorta which quickly 
follow one another, as with every systole it receives from the dilated 
and hypertrophied left ventricle an abnormally large quantity of blood, 
which it immediately disposes of in two directions — sending part back 
again into the ventricle, and part forward into the body. 

It is remarkable that also in heart-weakness there is sometimes a 
light, quick pulse. It is true that it is always very easy to compress 

1 See above, p. 208. '^ See this, p. 207/ 



210 SPECIAL DIAGNOSIS. 

it, and between the pulse-waves the walls of the artery fall together 
very decidedly (^pulsus vacuus, and at the same time celer). 

Pulsus taj'dus is an especial peculiarity of aoi^tic stenosis^ and at the 
same time it is generally smaller than normal. How much it may 
be diminished in size depends upon the degree of stenosis and the 
strength of the heart. Pulsus tardus occurs also with arterial sclerosis, 
likewise with lead colic, but also sometimes with other coHcs, as well as 
in peritonitis. 

Pidsus dicrotus will be more exactly described with the Sphygmog- 
raphy of the Pulse.^ 

3. According to the hardness of the pidse (tension of the arterial 
wall) we distinguish hard or tense and soft pulse, pidsus durus (tensus) 
— mollis. Here we must especially guard against confounding it with 
arterial sclerosis, which imparts to the wall of the vessel a hardness 
which has nothing to do with its tension. 

We test the hardness of the pulse by endeavoring to compress it 
with the finger. It is easy to compress a soft pidse. 

Again, it is really the power of the heart that produces these pecu- 
liarities, as well as the active tension of the wall of the vessel. In 
heart-weakness the small pulse is also always a soft pulse ; the large 
pulse is likewise often hard. With pidsus tardus there is almost 
always a strong action of the heart, and if the heart is hypertrophied, 
the pulse at the same time is often hard. When the pulse is quick 
there are constantly marked variations in its hardness. 

The hardness of the pulse is especially characteristic in contracted 
kidney with hypertrophy of the heart, also in lead colic (" wire pulse "). 
The pulse is tense also in apoplexia cerebri and in commencing menin- 
gitis, no doubt from irritation of the vaso-motor center. 

V. Basch has constructed a so-called sphygmomanometer, which is 
very useful for measuring exactly the tension in the arterial wall, and 
thus the blood-pressure. It has been brought out again lately, altered 
in construction.^ We omit a description of the apparatus and its mode 
of use, since each instrument is furnished with directions for using. 
We only remark that, in our opinion, it should be exclusively applied 
on the arteria temporalis, because here alone the conditions of the 
experiment are somewhat equal. And even here the apparatus very 
often indicates too low a blood-pressure. Normally, the pressure is 80 
to 1 10 mm. of mercury, and the range of values indicated by the instru- 
ment in healthy persons is much greater than corresponds to the 
variations of the arterial pressure. For this reason the instrument 
does not seem to be adapted for ascertaining the absolute height of 
pressure. But it is very practical for ascertaining the variations of 
pressure by continual observation on one and the same patient, if care 
is taken always, as far as possible, to make the conditions of the 
experiment equal. Of these the most important is to mark with color 
or a light line of nitrate of silver the exact portion of the temporalis on 
which is placed the so-called pulse-cap. 

5. Symmetry of the Radial Pulse. "^ — As has been already men- 
tioned, apart from anatomical variations of the artery upon one side, 
the pulse upon the two sides is perfectly alike as to time and quality. 

^ See p. 214. 2 G. Lufft, Eberhardtstrasse, Stuttgart. ^ Compare p. 216. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 211 

It may be disturbed, even to complete absence of the pulse upon one 
side. Ewald has found that the difference between the two radial 
pulses under some circumstances is made more distinct by raising the 
arm. Inequality is caused — 

1. By surgical diseases of the arm, as fracture of the bone, injuries 
or operations which displace the radial or which result in narrowing, 
compression, or cicatricial contraction of the radial, brachial, or axillary 
artery : in which case the pulse upon that side is found to be smaller. 

2. By hiniors of the chest-cavity, of the supra- or infraclavicular 
fossa, or of the axilla, which press upon the innominate, subclavian, or 
axillary artery of one side. They weaken the radial pulse even to 
complete obliteration. 

3. By aneurysm of the aorta, innominate} also by aneurysm of the 
subclavian, axillary, and brachial (all very rare).^ 

4. By emboli and antocthonous thrombi toward the center from the 
location of the pulse. In this case the pulse is commonly entirely 
wanting. 

5. In pneumothorax^ also large pleuritic exudation with compression 
and distortion of the subclavian. Sometimes the pulse upon the 
affected side is smaller, also frequently later. 

Sphygmography of the Radial Pulse. 

K. Vierordt originated the idea of sphygmography. With continued 
improvements of the apparatus the idea has been further developed by 
Marey, Wolff, Landois, Sommerbrodt, Riegel [and others]. 

Sommerbrodt's sphygmograph is the one now most generally used, 
but it has defects. Recently Ludwig has very decidedly improved 
upon Marey's instrument, as it seems to me. It can be obtained from 
Petzold, instrument-maker in Leipzig. [The instrument devised by 
Dr. Richardson of London is, in the opinion of the Translator, the 
most practically useful one yet brought out.] 

I am very much pleased with the sphygmograph of Jaquet (of 
Basle), which has a rest for the arm and a mechanism for measuring 
the time, and a twofold velocity. It fulfils every requisition that can 
reasonably be made with reference to sphygmography when the 
instrument is applied to the artery in its normal condition. The 
instrument can be very highly recommended. 

By others the sphygmograph of v. Frey (made by Petzold of 
Leipzig) is preferred, but I am sorr>' to say that I have no means of 
forming a personal judgment of it. 

What the sphygmograph really measures is the pressure of the 
pulse in the respective arteries. Therefore the instrument is only a 
refined [and recording] means of palpation. But it must be here 
emphasized that an absolute measure of the size of the pulse or of the 
internal pressure of the artery cannot be obtained in this way, as the 
height of the pulse-waves varies greatly with the position of the 
apparatus with reference to the artery and the position of the pad which 
receives the pulse. Hence it is well not to pay any attention at all to 
the height of the pulse-waves, but only to observe their form. 

^ In what way, see p. 219. 2 See works upon Surgery. 



212 SPECIAL DIAGNOSIS. 

In health the pulse-curve obtained with the sphygmograph shows 
elevations and depressions, ascending and descending lines, correspond- 
ing with the expansion and collapse of the artery. The expressions 
"apex-curve" {eg) and "curve at the base" (^) do not need further 
explanation. At both these points the curve stops only a very small 
portion of time. 

The ascension line {al^ is almost perpendicular; that is, the rise 
follows very quickly. The descent (a) is more drawn out and shows 
several small waves, which generally (not always) may be distinguished 
as a marked elevation (r), the backward-stroke elevation, caused by a 
wave of blood which results from the closure of the semilunar valve, 
and two (sometimes also three), or only one weaker, elevation produced 
by elasticity {e) ; the elastic secondary oscillation of the wall of the 
artery (according to Landois, but otherwise explained by others). 

The elevation (r), the " recoil," has hitherto been regarded as a 
positive centrifugal wave due to the closure of the aortic valves. 
Recently v. Frey and Krehl have come to the conclusion that this 
explanation is not tenable — that the question in the " recoil elevation " 
is rather with reference to a centripetal wave which is reflected by the 
peripheral end of the circulation of the body, as by the closed end of a 
tube. The opinion formerly expressed that r was more marked the 
nearer we were to the heart would then probably have to be explained 
by saying that it was the summation of the waves which originate in 
various individual arterial regions, and are thence reflected. 

But this view has met with strong opposition, and we too cannot 
avoid sharing in the opinions which have been brought against it, par- 
ticularly by Hiirthle, and are rather inchned to return to the old 
opinion. 

However that may be, the quality of the " recoil elevation" has this 
diagnostic value : it increases with the diminution of the tension of the 
artery ; its presence or absence, and in the former case its size, forms 
in itself a certain measure for judging of the blood-pressure ; likewise, 
but in a reversed sense, when the " elasticity elevations " are very pro- 
nounced we must assume that there is considerable pressure. It is to 




Fig. 70. — Normal pulse-curve in a healthy man, aged twenty-five years (after Eichhorst). 

be remarked regarding the sphygmography of other arteries that r 
becomes more marked the nearer we go to the heart. 

The following are the essential pathological forms of sphygmographic 
pulse-waves : 

I. A descending line with several very marked elasticity elevations, 
but smaller backward-stroke elevations (often difficult to make out) 
which correspond with the increased tension in the aortic system {lead 
colic, contracted kidney, acute nephritis, etc.). 



EXAMINATION OF THE CIRCULATORY APPARATUS. 



213 



2. On the other hand, diminution of the elasticity elevation with 
more marked backward-stroke elevation shows diminished blood- 
pressure. Such increase of r is called "dicrotic," and the pulse 
" dicrotic pulse." Such a pulse, even if it is only moderately pro- 




FlG. 71. — High-tension pulse. 

nounced, can be recognized by palpatio7i. It occurs in certain condi- 
tions which accompany a moderate diminution of strength of the heart, 
but especially a diminution of the tone of the arteries : 

a. In acute febrile diseases, and indeed in so marked a degree and 
so early in typhus abdominalis [typhoid fever] that in diagnosis we may 
attach some, though not too great, value to this symptom. 

b. In chronic wasting diseases, especially febrile — more than others 
in tiibercidosis. Here, according to my observation, it is not infre- 
quent. 

c. In other weak conditions, as after great loss of blood, and in 
general in all forms of anemia. 




r\) ^-w vai 



\^\ 



vHH^J 



^rJ\AVJ\rS\rJ\jJ\^A 



Fig, 72.— Difterent forms of dicrotic pulse (after Eichhorst).' 

The above curves show that in the dicrotic pulse the backward- 
stroke elevation may fall in the descending line (.??^M/^r^/?r/?//.y^), as 
well as in the middle of the basis curve {complete dicrotic ptdse), hk^^is^ 
in the ascending line of the next following wave {super dicrotic pulse). 
The so-called mojiocrotic pulse (no visible backward-stroke elevation) is 
a sort of superdicrotic pulse. 



214 



SPECIAL DIAGNOSIS. 



What has been said in general regarding dicrotic pulse expresses 
the diagnostic value of all these forms of pulse. 

3. To the pulsus celer corresponds a curve with a very steep ascend- 
ing line and an unnaturally high apex-curve (in consequence of the 
quickness of the arterial diastole the recording lever of the apparatus is 
always thrown too high up). Moreover, the apex-curve is sharp- 
pointed, and the descending line is almost as steep as the ascending 
line. The elasticity elevations are marked. With pulsus celer due to 
aortic insufficiency there is, of course, no backward-stroke elevation, as 
the semilunar valve does not close.^ 




Fig. 73. — Pulse-curve in aortic insufficiency (after Striimpell). 

4. Pulsus tardus, as in palpation ^ so in the curve, is the exact oppo- 
site of the preceding. With it there are usually more complete loss of 
the elasticity elevation and indistinct backward-stroke elevation. 



Fig. 74. — Pulse-curve in stenosis of the aortic orifice (after Striimpell). 

A peculiar combination of pulsus celer and tardus manifests itself 
with insufficiency and stenosis of the aorta. 

In pulsus tardus the quickness of the apparatus is completely want- 
ing on account of the slowness of the ascension ; hence it always seems 




Fig. 75.— Pulsus tardus in atheroma of the arteries (after Eichhorst). 

small in comparison with the normal pulse-wave, and with that of 
pulsus celer ^ still smaller than is really the case. 

It is quite impossible to form an estimate of the size of the pulse 

1 Compare what has been said on p. 209 upon Pulsus Celer. ^ See p. 209. 

3 See this. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 



215 



from the sphygmographic curve. The unequal pulse will generally be 
very beautifully delineated by the apparatus, but it cannot be more 
exactly depicted than it can be learned by exact palpation. It is true 




Fig. 76. — Pulse with anacrotic elevation in aortic insufficiency, with moderate stenosis of the 

orifice and arterial sclerosis. 

that the apparatus includes small waves that the finger cannot recog- 
nize, but often these cannot be distinguished from the elevations indi- 
cating the backward stroke. 




Fig. 77. — Pulse-curve with marked mitral stenosis (after Strilmpell). 

The rhythm of the pulse will, of course, even if only for a very 
short distance, be very well exhibited, and it is in this direction that 
the graphic delineation is very useful in giving instruction. But here 
sphygmography is wholly wanting for diagnostic purposes, since every 
notable useful irregularity can be felt just as well. 

Annexed is an example of pulsus bigeminus (after Riegel). 




Fig. 78. — Pulsus bigeminus (after Riegel). 



The application of the sphygmograph to both radial arteries simul- 
taneously and comparison of the records will sometimes markedly 
increase the discrimination with reference to the symmetry of the radial 
pulses. Recently v. Ziemssen has shown that if the left subclavian 
artery is narrower at the point where it is given off from the aorta, the 
radial pulse of that side is very decidedly changed. He shows oblique 
lines of ascension, lowering, and retardation of the summit of the curve 
and monocrity, as is apparent from the accompanying figure. 

Von Ziemssen designates this as pulsus differens in the narrower 
sense. This corresponds, as has been stated, with a narrowing of the 
subclavian at its origin, and it will be found in aneurysm of the arch of 
the aorta if associated with a stenosing endarteritis of the origin of the 
subclavian or a dragging of this vessel, or, finally, with compression of 
the commencement of the left subclavian artery. We may also expect 
to have the pulsus differens in compression of the left subclavian by 
any sort of tumor, by pneumothorax, and by a very large pleuritic 



2l6 SPECIAL DIAGNOSIS. 

exudate. Aneurysmal dilatation of the aorta by itself — that is, without 
stenosis of the subclavian — does not seem to give rise to this pulse.^ 




Fig. 79. — Pulsus differens : Aneurysm of aorta with stenosis of the mouth of left subclavian 

artery (after von Ziemssen). 



Diagnostic Value of the Examination of the Pulse. 

From what has been said it is sufficiently evident that for the pur- 
poses of diagnosis palpation of the radial pulse is preferable to sphyg- 
mography. The latter is more circumstantial, and gives, with a few 
exceptions, to one sufficiently practised in palpation no better result 
than the former. It very easily even deceives, especially regarding the 
size of the pulse, but sometimes also its form, from reasons that lie in 
the apparatus. Except in individual cases — as, for instance, when this 
question is in regard to pulsus differens — the great value of the sphyg- 
mograph for the clinician consists chiefly in its usefulness in giving 
instruction, for exhibiting a characteristic anomaly of the pulse to a 
large number of hearers, or it may serve to show a pupil what he 
ought to feel. 

In what follows will be briefly indicated in which direction the 
examination of the pulse is of value for diagnosis, and how it can be 
turned to account : 

I. Very often the pulse directly serves to determine the diagnosis — 
not that it alone is sufficient, but in connection with other phenomena 
it is. We are to bear in mind here what has previously been said 
regarding the behavior of the pulse in the various febrile diseases. 
But in diseases of the heart it especially has such an important place 
that a diagnosis is never to be made without taking into consideration 
the condition of the pulse. 

In what follows is brought together what can be said regarding the 
behavior of the pulse in the most important of the diseases of the heart 

Mitral iiisiifficiency : The pulse does not markedly or notably vary 
from the normal. But in addition the signs of hypertrophy of the 
right and left ventricles are present — systolic murmur at the apex. 

Mitral stenosis : In classical cases, even with good compensation, 
pulse is small, unequal, or irregular, its frequency often much increased. 
Indeed, not infrequently these pulse signs are absent, and the pulse 
does not to any great extent depart from the normal. (In addition, 

1 Compare further p. 211 ; also p. 218 /J Aneurysm of Aorta. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 21/ 

there are signs of hypertrophy of the right ventricle and a presystohc 
murmur at the apex.) 

Aortic insufficiency : Pulse is quick, frequency either normal or in- 
creased ; generally equal and regular. In addition there are the signs 
of hypertrophy of the left ventricle and a diastolic blowing murmur at 
the aorta. (For the conditions at certain arteries, etc., see below, 
page 220 /.) 

Stenosis of the aorta : Pulse is small, slow, normal or diminished in 
frequency, equal and regular. In addition, there are signs of hyper- 
trophy of the left ventricle ; only the apex-beat is often very strong 
and a systolic murmur heard over the aorta. 

Myocarditis : Pulse is more or less small and soft, almost always 
irregular in quality, and generally so in time (here especially we have 
sometimes pulsus incidens, bigemimis). Frequency is increased, nor- 
mal, or diminished. Nothing abnormal at the heart, or signs of dila- 
tation of one or both ventricles ; no murmurs. 

Pericarditis exudativa : Pulse is strong if the heart remains so, gen- 
erally somewhat quickened. In addition, at the heart all signs of its 
activity are diminished or removed by being covered over, marked 
dulness ; in paralysis of the heart no pulse or very much quickened ; 
sometimes pulsus paradoxus. 

We are particularly to notice the opposite condition of the pulse in 
aortic insufficiency and stenosis, and also that in myocarditis the pulse 
may be the only sign. 

In combined valvular disease the pulse is of importance in two ways : 
it betrays the existence of a second valvular disease besides the one 
already made out, as is especially the case in mitral insufficiency and 
stenosis. The latter near the former may be overlooked because very 
slight, or may even be entirely wanting, and because it produces hyper- 
trophy of the right ventricle, which is also produced by the former, for 
there may be a very small, unequal, irregular pulse, which alone indi- 
cates the stenosis. Also, an aortic stenosis, besides insufficiency of the 
aorta, is sometimes certainly discovered only by the pulse, since there 
may be a weak systolic murmur at the aorta without stenosis. Thus 
the decision as to which cardiac orifice is concerned in the murmur, or 
whether we have one murmur widely conducted or two murmurs inde- 
pendent of each other, may be determined by the pulse. 

Moreover, in a patient with combined valvular disease the pulse 
may very greatly assist in determining which disease is to be regarded 
as the more marked or important. This is especially true in insuf- 
ficiency and stenosis of the aorta (the distinctness of the murmurs is, 
of course, not at all indicative ; ^ also of the mitral or for combined 
disease of the aortic and mitral valves. 

Thus we would diagnosticate a preponderating insufficiency and a 
very slight stenosis of the aorta when we have the signs of hyper- 
trophy of the left ventricle, a loud sawing systolic and a very slight 
diastolic aortic murmur, and a pronounced pulsus celer. Thus, with 
the signs of aortic insufficiency and mitral stenosis a very small pulse 
points to the preponderance of the latter. 

It is very difficult or even impossible to make a diagnosis of the 

^ See above. 



2l8 SPECIAL DIAGNOSIS. 

particular heart-lesion, either from the general symptoms or from the 
pulse, so long as there is continued evidence of incompensation. 

Moreover, in the cases where the heart and its action are concealed, 
especially in pericarditis exudativa, also in emphysema, sometimes in 
marked deformity of the thorax, displacement of the heart, tumors of 
the chest-wall, the pulse is the only sure sign of what work the left 
ventricle is doing. In pericarditis the contrariety that exists between 
a diminishing apex-beat, the slight, almost imperceptible heart-sound^ 
and a strong pulse is sometimes a very important diagnostic point. 

2. The pulse enables us to judge of the strength of the heart in all 
other possible — especially febrile — diseases. Even the first examination 
of the pulse furnishes, in this case, important information ; but the 
signification of indications furnished by repeated examinations of the 
pulse (palpation and representation of its varying frequency upon the 
temperature-chart) becomes very much more valuable. These indica- 
tions furnish still more important diagnostic points, some of which 
have already been spoken of They have reference to the beginning 
of complications in acute infectious diseases, especially those affecting 
the heart, the lungs (which are very frequent), the kidneys (as after 
scarlet fever, when the pulse has greater tension and diminished fre- 
quency), and to the brain (decline in frequency in meningitis). Also, 
the effect of treatment, as of cold baths, may be determined partly by 
the behavior of the pulse ; in general, it often determines the treat- 
ment. 

We must also mention all diseases which in any way affect the 
heart, as pleuritis, pericarditis, peritonitis, in which the pulse, especially 
as a measure of treatment, has any part. 

n. other Phenomena in Arteries. 

The Aorta. — Sometimes a pulsation is to be seen and felt in the 
neck : exceptionally also in health in consequence of higher location 
of the arch of the aorta ; likewise in hypertrophy of the left ventricle, 
most marked in aoi'tic insufficiency , since this causes a broadening of 
the commencement of the aorta ; and, finally, in aneurysm of the arch 
of the aorta. 

The occurrence of pulsation that can be seen and felt in the right 
second mtercostal space is always pathological. It occurs in hyper- 
tropJiy of the left ventricle, and also especially m insufficiency of the 
aorta ; further, in aneurysm of the aorta. In rare cases, when there is 
marked hypertrophy, the second aortic sound may be felt, which, of 
course, can never be the case in aortic insufficiency. 

In rare cases of aortic insufficiency the commencement of the aorta 
is accessible for percussion. It is to be remembered that here it is 
very much broadened, and to the right of the sternum, from the lower 
border of the second rib to the third rib, there is a small area of dul- 
ness. Sometimes over the aorta (in the right second intercostal space) 
in marked atheroma there ought to be heard a systolic murmur, even 
when there is no endocarditis aortica. 

Aneurysm of the aorta requires a special description. It most 
frequently occurs in the ascending portion or the arch of the aorta, and 



EXAMINATION OF THE CIRCULATORY APPARATUS. 219 

gives rise to the following phenomena : Only when the aneurysm is 
large is a sweUing to be seen, and this, if present, is seen either above 
the sternum or close to the right of it. It generally pulsates — that is, 
becomes larger in all directions — with the systole of the heart. From 
stagnation ^ the enlarged veins of the skin are very early visible ; later 
they may become red from inflammation or even be necrotic. In large 
aneurysm, under some circumstances, when we palpate we feel the 
pulsation, and besides, not infrequently, a peculiar whizzing or thrill. 
With large tumors, also, it further shows that the bones and cartilages 
over them have been absorbed. Repeated nieasiirement of tlie tliorax 
shows a gradual increase of the sterno-vertebral diameter. Percussion 
generally very early exhibits dulness, usually on the right, close to the 
sternum and over the manubrium ; more rarely to the left of the ster- 
num, and this either in connection with the area of heart-dulness or dis- 
tinct from it. Auscultation not infrequently reveals the systolic whizzing, 
which has already been referred to as being felt, or also only two dull, 
impure sounds, or they may not be heard at all. The radial pulse, also 
the carotid, is not infrequently at an early stage upon one side smaller 
and a little later than on the other, in consequence of the compression 
of the particular branches of the aorta or distortion of their openings 
at the point of origin. Aneurysm of the ascending aorta affects the 
vessels of the right side, and aneurysm of the arch of the aorta some- 
times affects those of the left side.^ Not infrequently also there exists 
insufficiency of the aorta with hypertrophy of the heart. By all tumors 
in this neighborhood the heart may be crowded toward the left side.^ 

Aneurysm of the innominate produces about the same local symp- 
toms as aneurysm of the ascending aorta, only generally somewhat 
higher up. 

Aiteurysm of the descending aorta (rare) may produce corresponding 
phenomena upon the left side, posteriorly, near the spine. The pulse 
in the abdominal aorta and its branches is usually later. 

Aneurysm of the abdominal aorta (likewise rare) is generally at the 
level of the tripus coeliacus. It may be felt as a pulsating tumor in 
the upper part of the abdomen, and sometimes exhibits the whizzing 
mentioned above. 

Considerable stenosis, or even closure, of the aorta at the junction of 
the ductus arteriosus is a very rare congenital condition, which is rec- 
ognized by the fact that certain arteries furnish collateral circulation 
between the ascending aorta and the region of the descending thoracic 
aorta or the abdominal aorta. These collateral vessels become very 
much enlarged, and pulsate so as to be seen and felt. Diagnostically, 
the most important are the internal mammary, the anterior superior 
and inferior epigastric anteriorly, the transversus scapulae and dorsalis 
posteriorly. 

The Pulmonary Artery. — In very rare cases aneurysm of the 
pulmonary artery may give rise to almost the same symptoms as 
aneurysm of the aorta, except in being at the left of the sternum ; that 

^ See p. 224. 2 Compare Pulsus differens, p. 215. 

^ See further, under Examination of the Larynx, regarding the evidences of pressure by 
these tumors upon the trachea, upon the esophagus, upon the left recurrent nerve (seldom the 
right). Regarding pressure upon the large veins, see p. 224. 



220 SPECIAL DIAGNOSIS. 

is, if it is a question whether there is aneurysm of the pulmonary 
artery. A systohc murmur over the pulmonary artery may, besides, 
be caused by stenosis of the pulmonary opening or by narrowing of the 
artery itself. This may be congenital or be developed later, in the 
latter case by shrinking of the upper portion of the left lung. In such 
cases the second pulmonary sound is generally accentuated (hyper- 
trophy of the right ventricle), and under some circumstances may even 
be felt.i 

The Other Arteries. — Inspection.— Excepting during excitement 
of the heart (by mental excitement or physical exertion) we observe in 
health a visible pulsation of the carotid in the neck just under the 
angle of the jaw ; also of the temporal artery. A marked pulsation of 
the carotid — especially when there is perfect mental and physical 
quietude, or, again, a general visible pulsation of smaller vessels, as of 
the temporal, the brachial, in the sulcus of the brachial muscle or at 
the bend of the elbow, of the radial, peroneal, dorsalis pedis — points to 
hypertrophy of the left ventricle. These abnormal pulsations are most 
marked in insufficiency of the aortic valves and in arterial sclerosis ; in 
the first case on account of the fulness of the pulse, in the latter case 
on account of the thickened and stiffened vessels being prominent. In 
both classes of cases the smaller arteries are very tortuous. 

Here also a capillary pulse is to be mentioned : alternating between 
marked fulness and emptiness of the capillaries, occasioned by the 
pulse in the arteries, the pulse may become visible under the finger- 
nails, more rarely over the tendons, in case these variations are con- 
nected with a large and quick pulse in the arteries, which, in turn, have 
large and quick alternations of size. Then, in examining the finger- 
nail, we see the red part rhythmically become alternately white and 
red — capillary pulse of the bed of the nail? This is a sign of aortic 
insufficiency with marked hypertrophy of the left ventricle (which 
would also be present in some cases of marasmus). 

Palpation. — Medium-sized and small arteries sometimes feel thick- 
ened and moderately stiff, or scattered in their walls we feel separate 
rigid patches, very like the plates of cartilage of the bronchial tubes or 
the rings of ' a small trachea (" goose's throat "). The latter become 
especially plain if we slip the tip of the finger up and down along the 
course of the artery. This is the condition in arterial sclerosis. Hence 
the vessels are often tortuous^ and show variations of the pulse.* It is 
very easy to recognize arterial sclerosis in the temporal, radial, and 
brachial arteries. From the condition of these we can correctly esti- 
mate the condition of other arteries of the same size. 

Palpation of the radial artery has already been described. Of the 
other arteries of the extremities the pulse of which we can feel in 
health, we may mention the brachial, in many persons the ulnar, the 
crural, the popliteal, and in most people the peroneal. Increased 
pulsation in arteries that can be felt, its occurrence in small arteries 

^ See above. 

^ [This is often an unfavorable situation for making the observation. Quincke, v^^ho 
first described the capillary pulse, now recommends rubbing gently a spot upon the forehead. 
— Berliner klin. Wochenschr., Mar. 24, 1 890.] 

3 See above. * See this. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 221 

that can be felt, which in health are never made out, takes place in 
aortic insufficiency. A pulsation that can be felt in the dorsalis pedis 
artery is here very frequent, but the same thing may take place in still 
smaller arteries — in the digital, in the coronariae labii inferior., superior., 
and the like. Very exceptionally in aortic insufficiency we may even 
observe an arterial liver-pulse ; that is, a continuous to-and-fro swell- 
ing of the liver from the marked pulse in the arteries of the liver 
(quite Hke the venous Hver-pulse).^ Still more rare is an arterial pulse 
at the spleen.^ 

When in symmetrical vessels, like the two radials, we find a pnlse 
that is ujieqnal as to strength or time, we may generally conclude that 
there is a mechanical hindrance to the passage of the blood-current. 
We then have to seek toward the center from the weaker or later 
pulsating artery for a compressing tumor, thrombosis (autochthonous 
or embolic), or for an aneurysm. Moreover, there are observed 
variations of the pulse in symmetrical vessels, caused by vaso-motor 
influences from the nerve-centers. Finally, we must not overlook the 
possibility of anatomical variations. 

Auscultation. — Mode of procedure : Here, it is to be understood 
throughout, the stethoscope is to be employed, and that ordinarily it is 
to rest upon the surface without pressure. We auscultate the carotid 
with the neck somewhat extended, but not stretched, in the intersterno- 
cleido-mastoid fossa or at the angle of the jaw ; the subclavian, in the 
angle between the clavicle and the clavicular head of the sterno-cleido- 
mastoid muscle ; the brachial, on the inner border of the biceps in the 
bend of the elbow, with the arm slightly extended ; the crural, close 
below Poupart's ligament. 

Normal Condition. — In health we usually hear over the carotid, as 
well as the subclavian, two sounds — one corresponding to the pulse, 
with the systole of the heart (the conducted aortic first sound and local 
diastolic sound in the vessel). In individual cases the first sound is 
impure or is entirely wanting. In health the diastolic heart-sound is 
never wanting. We sometimes hear over the abdominal aorta and the 
crural artery a sound which corresponds with the pulse, or, at any 
rate, arises locally from the tension of the vessels. We usually hear 
nothing over any of the small vessels. If we press with the stetho- 
scope over the given vessel, then we hear the so-called acoustic 
pressure-sound, not alone over the aorta and subclavian, but also 
regularly over the abdominal aorta and crural artery, and usually, 
also, over the brachial. Thus, by moderate pressure over these vessels 
we hear a pressure-murmur corresponding to the arterial pulse ; by 
stronger pressure, which almost, but not quite, closes the artery, this 
murmur is changed into a tone — pressure-tone. That these acoustic 
phenomena, resulting from pressure, are everywhere present are the 
chief reasons why the pathological conditions over the large vessels 
which are to be mentioned later have only conditional diagnostic value. 

We must also mention a phenomenon frequently present in healthy 
children, called " cerebral blowing ;" it is heard between the third 
month and the sixth year with the systole of the heart, or, more 
exactly, as a blowing corresponding with the carotid pulse, which is 

^ See p. 228. 2 See under Examination of the Spleen. 



222 SPECIAL DIAGNOSIS. 

heard sometimes light, sometimes tolerably loud, over the fontanelle 
while still open, but also sometimes after it has closed, and elsewhere 
over the head. Jurasz has in most cases found at the same time a 
blowing over the carotid, and thinks that the cerebral blowing is 
merely this murmur conducted upward. He explains the latter by the 
compression which the carotid sustains in the carotid canal during the 
development of the skull. 

Pathological Conditions. — In aortic stenosis there will be heard 
over the carotid, in place of the first sound, a rough systolic Jieart- 
miirinur (the stethoscope must rest very lightly). 

In aortic insufficiency the second sound of the carotid and sub- 
clavian is wanting, or it is replaced by blowing with the diastole of the 
heart (rare). This, as well as the systolic murmur previously men- 
tioned, is conducted from the mouth of the aorta. The former, 
arising in a current of blood flowing forward, would naturally, as a 
rule, be more loudly conducted than the latter, which comes from a 
backward-flowing blood-current. 

Sounds in such arteries as in health very seldom or never furnish a 
sound accompany aortic insifficiency, being produced by the quick and 
strong tension of the vessels during their diastole. We then hear a 
sound corresponding with the pulse over the crural, brachial, radial, 
even the ulnar, peroneal, dorsalis pedis arteries ; sometimes even over 
still smaller vessels. A sound is also observed over the crural in higJi 
fever, as well as in anemia and clilorosis (and as well in some healthy 
persons). 

A double sound over the crural arteiy (Traube) is heard in indi- 
vidual cases of aortic insufficiency. But this phenomenon has also, 
although very exceptionally, been observed with mitral stenosis (Weil), 
likewise in lead-poisoning (Matterstock) ; lastly, in pregnancy (Ger- 
hardt). Much more important is the double murmur which is heard 
when considerable pressure is made with the stethoscope — Duroziez's 
double mnrniur. In the experience of observers, thus far, this occurs 
only with aortic insufficiency, and this when there is good compensa- 
tion ; and this has all the greater significance from the fact that it is 
decidedly more frequent than was previously supposed. 

Double sound, as well as double murniur, can only occur when 
there is a large and quick pulse. , In the first phenomenon the double 
sound is caused by the sudden collapse of the artery ; with double 
murmur the second murmur is probably to be explained by the short 
reflux blood-current which may be assumed to flow into the large 
vessels when there is aortic insufficiency (?). A double sound can 
also be heard over the crural artery if one of the two sounds, or even 
if both sounds, arise from the crural vein.^ 

A systolic subclavian murmur is sometimes heard on both sides, or 
sometimes only on one side (especially the left), as a very disturbing 
addition to the breath-sounds at the apex of the lungs. It is stronger, 
or perhaps only to be heard, toward the end of inspiration. When it 
occurs upon both sides, as a rule, it does not indicate a pathological 
condition; when unilateral, it also has no significance, and yet it always 
gives the suspicion of phthisis, with which we often meet it. It is ex- 

^ Regarding this, see next chapter. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 223 

plained by a temporary pulling or bending, and hence narrowing of the 
subclavian artery during deep breathing. In phthisis this is caused by 
adhesion of the pleural surfaces at the anterior surface of the apex of 
the lungs. We do not know exactly why this murmur occurs also 
with persons apparently perfectly healthy, but it may possibly be from 
the same cause. 

Loud blowing murmurs over the thyroid glands sometimes occur in 
all forms of struma. These murmurs may be felt. They are not in- 
frequent with struma of Basedow's disease, but here they are caused by 
the excited action of the heart. 

The murmurs which in some cases are heard over aneurysm have 
been already mentioned. 

EXAMINATION OF THE VEINS. 

We examine chiefly, in many cases exclusively, the jugular veins 
(external and internal in the neck), but also the cutaneous veins of the 
body and extremities. Only in special cases (thrombosis) do the deep 
veins of the extremities become accessible for examination. The 
ophthalmoscopic examination of the ophthalmic veins does not come 
within the scope of this book. It is important that we are able to 
judge of the abnormal fulness (engorgement) of certain deep veins by 
its effect upon particular internal organs, as enlargement of the liver 
and spleen, also ascites, and, lastly, the suppression of urine.^ 

The examination of the veins is made by inspection, or sometimes 
by palpation and auscultation. 

Inspection and Palpation of Veins. 

By these means we ascertain the degree of fulness, the condition of 
the circulation, and, under some circumstances, the existence of venous 
thrombosis. An unusually empty condition of the veins does not come 
under consideration. This would also be very difficult to determine, 
for the reason that even in health, especially in fat people, the super- 
ficial veins may be indistinct or entirely invisible. It remains to 
describe — i. Increased fulness of veins; 2. Circulation in the veins of 
the neck ; 3. Circulation in the other veins ; 4. Venous thrombosis. 

I. Increased Fulness of Veins. — This is the result of stoppage 
of the blood in its course toward the centre. It is general or local 
according to the cause of the engorgement, whether this be central or 
at some place in the course of the nerves that control the circulation. 

General increased fulness is the result of general venous engorge- 
ment. We first recognize it by the swelling of the internal and exter- 
nal jugular veins upon both sides. The first of these is usually visible 
in health (but not always, especially in fat people), coursing obhquely 
over the sterno-cleido-mastoid muscle. When the head is turned 
toward the opposite side it usually swells still more. With the 
increased fulness it becomes distinct, perhaps can be felt. With nor- 
mal fulness the internal jugular cannot be made out, situated, as it is, 
under the sterno-cleido-mastoid muscle, where it is divided into the 

^ See under Enlargement of Liver, of Spleen, also Ascites and the so-called Urine of 
Engorgement. 



224 SPECIAL DIAGNOSIS. 

clavicular and sternal portion, just in the angle between these, at the 
bottom of the intersterno-cleido-mastoid fossa. Where it passes into 
the bulbus jugularis it has a valve (ordinarily exactly at the upper 
border of the sterno-clavicular articulation, but sometimes, especially 
in consequence of the engorgement, located somewhat higher). Ab- 
normal fulness of the jugular vein fills up the intersterno-cleido- 
mastoid fossa or it may cause a projection there. Dorsal posture 
increases the fulness. Fulness of the cutaneous veins of the trunk and 
extremities, not occurring without general engorgement, is usually not 
so pronounced as that of the veins of the neck, especially on account 
of the marked edema which accompanies the congestion. Important 
associated symptoms of general engorgement are cyanosis, edema, 
effusion into the cavities of the body, enlargement of liver and spleen^ 
disturbance of the bowels, and so-called urine of engorgement} 

This condition arises when the right heart is not able to propel the 
required quantity of blood into the lungs. It occurs in various dis- 
eases of the heart, in emphysema of the lungs, and in all the conditions 
that lead to marked interference with the action of the heart, especially 
pericarditis. The most marked engorgement occurs in general when 
the right side of the heart is paralyzed after it has been obliged for a 
long time previously to meet unusual demands, and hence has become 
hypertrophied ; hence with mitral 2.wdi,n\ox^ rdi\'e\y, ptilmonary defects diUd 
emphysema, diud likewise in the very rare tricuspid stenosis ^.Vid.insufficieiicy?' 

General abnormal fulness of the veins may also be the result, 
exceptionally, of diminished flow of blood from the two cavae into the 
right auricle in consequence of pressure by a mediastinal tumor. 

Local increased fiilness of the veins may be caused by a consider- 
able narrowing or closure anywhere of a venous trunk by a thrombus 
or by compression. The larger the vessel thus affected, the more 
extensive the area of abnormal fulness. Thus, sometimes abnormal 
fulness of the jugular and its branches, also of the ophthalmic vein 
(recognized by the ophthalmoscope), will be caused by a mediastinal 
tumor which presses upon the cava. Also the superficial veins of the 
skull between the ear and the fontanelle will become distended and 
tortuous if the longitudinal sinus of the dura is stopped. Fulness of 
the veins of an arm points to compression of the axillary vein (gener- 
ally tumors or scars from operations in the axilla). The swelling of 
the veins of the skin over or on either side of the sternum is a very 
important early sign of mediastinal tumor. The cutaneous veins of 
the leg are enlarged when there is thrombosis or compression of the 
femoral vein of that side. The veins of both legs may swell as the 
result of double thrombosis or compression of the vena cava inferior 
or both iliac veins (ascites, tumors). In all these cases there may be 
local edema.^ This may even give a better and earlier sign of local 
engorgement, but, on the other hand, it may conceal the fulness of the 
veins. 

In the majority of such cases the cutaneous veins supply the neces- 
sary collateral circulation. But this is especially the case in engorge- 
ment of the portal vein,^ whether due to cirrhosis of the liver or com- 

1 See this. ^ gge under 3, p. 229. ^ See this, 

* See also Enlargement of the Spleen, and Ascites. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 22$ 

pression or thrombosis of the portal trunk. Here we may see the 
abdominal veins enlarged, part of which go upward to the thorax and 
part downward to the inguinal region. In individual cases there is a 
crown of such veins around the navel — " caput Medusce " — since the 
umbilical vein, remaining open, receives a part of the overflow of blood 
which the portal is not able to carry. 

The fine dendritic vein-nets which are frequently seen on the lower 
portion of the chest, and here and there also on the back along the 
course of the lower boundary of the lungs, more rarely along the 
sternum or in the fossae supraspinatae, are difficult to interpret. They 
appear most frequently in emphysema of the lungs, and also in adhe- 
sive pleuritis. I have lately found them three times within a short 
period in cases of adhesive pericarditis on the boundary between the 
heart and lungs. Probably they are always signs of collateral circula- 
tion, which in pleural coalescence it is certainly not difficult to under- 
stand, but more difficult in emphysema. However, such vein-nets are 
sometimes also seen in persons in whom no anomaly of the thoracic 
organs can be found. 

Very extensive enlargement and tortuosity of a large part of the 
cutaneous veins of the trunk or of the chest (generally symmetrical), 
or enlargement of single cutaneous veins of an extremity, also occur 
without any possible assignable cause (perhaps closure of a deep 
branch), so that, according to the views of the present day, it is to be 
regarded as an independent primary alteration of the respective veins. 
Whether this alteration is to be considered as a congenital disposition 
or an anomally gradually acquired later, possibly a kind of chronic 
phlebitis, cannot yet be decided. 

3. Phenomena of Circulation in the Jugular Veins.— Respi- 
ratory Motions. — The suction action of the chest with inspiration 
causes a rapid emptying of the blood from the veins of the body into 
the heart during inspiration, as well as during expiration. On the 
other hand, a forced expiration, likewise strong effort, and very espe- 
cially the increased internal pressure within the chest which takes place 
in coughing before each cough-impulse, check the discharge. The 
alteration in the fulness of the veins in the neighborhood of the heart 
which is thus caused is usually only to be observed in the jugular 
veins. But in normal fulness of these veins the simple respiratory 
oscillation of their volume is not noticeable. Such veins only distinctly 
swell with marked pressing and coughing (whooping-cough), and then 
the veins of the face become very full. Yet when the yeins of the neck 
are constantly abnormally full or engorged, then in ordinary breathing 
they show a corresponding to-and-fro swelling, and with forced expira- 
tion, pressing, or coughing they stand out very distinctly. The bulbus 
jugularis may then appear as a round bunch between the heads of the 
two sterno-cleido-mastoidei muscles ; but even the whole internal 
jugular may swell and contract if the valve over the bulb does not 
close. This phenomenon occurs in the most marked degree with the 
labored expiration of emphysema. Here, also, in very rare cases, this 
variation in the fulness extends to the cutaneous veins of the face, the 
chest, and arms. 

The opposite condition of the veins of the neck, becoming tumid 

15 



226 



SPECIAL DIAGNOSIS. 



with inspiration and emptying with expiration, may be caused by- 
fibroid mediastinitis (mediastino-pericarditis). The cause of the phe- 
nomenon, Hke that of pulsus paradoxus^ is the traction and bending of 
the large vessels during inspiration (Kussmaul). 

Venous Pulse. — Circulatory movements in the veins of the neck, 
which directly or indirectly depend upon the action of the heart, and 
hence are rhythmic, are designated as venous pulse. This motion may 
be communicated to or really be in the vessels (autochthonous, real 
pulse). The former is only the pulsation in the carotid communicated 
to the internal jugular, which shows most frequently and plainly when 
the carotid pulsates very strongly or when the internal jugular is very 
full, or if both conditions exist.^ 

We divide the real venous pulse, pulsation in the veins of the neck, 
into that which occurs in health, the so-called " normal " or negative, 
and the positive, which is always pathological. The normal venous 
pulse is presystolic, and usually is only observed in the external jugular. 
It would be best designated as a collapse of the vein accompanying the 
systole of the heart; for the external jugular, in exact correspondence 
with the apex-beat and the carotid pulse, quickly empties itself, and 




Fig. 8o.- 



-Normal venous pulse or venous collapse v^Wh systole of the heart, and (broken line) 
carotid pulse (after Riegel). 



immediately again slowly fills, sometimes visibly in two intervals, so 
that it attains its complete distention before the next systole of the 
heart, and hence is presystolic. 

This phenomenon depends upon the part the auricle plays in the 
action of the heart : during the ventricular systole it is in diastole, and 
thus favors the flow of blood from the veins. Shortly after the begin- 
ning of the ventricular diastole it begins to contract, and thus the flow 
of the venous blood from the cava into the auricle is impeded. It 
seems to me that the first elevation of the ascending side of the tracing 
of the curve of the venous pulse has not yet been explained. In health 
this pulse is seen to a very small, scarcely noticeable, degree ; it is 
beautifully seen in dogs when the jugular is laid bare. In healthy per- 
sons, without any known reason, it is in some cases strong enough to 
be observed. But sometimes it is still stronger when the external 
jugular is abnormally full, hence in engorgement. Often this pulse 
occurs only indistinctly ; its rhythm is difficult to recognize, and it is 
also affected by the pulsations of the carotid. Then we speak of 
U7idiilation in the veins of the neck. 

1 See this. ^ For distinction between this and genuine systolic venous pulse, see p. 227. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 22/ 

The positive venous pulse is systolic, hence is contemporaneous 
with the carotid pulse. It is a pathognomonic sign of insufficiency of 
the tricuspid valve, and is caused by che contraction of the right ven- 
tricle, which causes a regurgitant positive blood-wave into the cava 
and its nearest branches through the imperfectly closed right ostium 
venosum. It first and most markedly appears in the internal jugulars 
or their bulb, and generally only here. The very direct course of the 
innominate and right jugular from the cava causes the right jugular 
vein to show the phenomenon more frequently and stronger than the 
left. 

If the valve of the vein closes above the bulb of the jugular, then 
the regurgitant wave ends there. This pushes the bulb up and distends 




Fig. 8i. — Positive jugular pulse compared with {€) carotid pulse (after Riegel). 

it, and it is then seen, enlarged and pulsating, in the intersterno-cleido- 
mastoid fossa {bulbar pulse). The bound of the pulse-wave against 
the valve sometimes causes a valvular sound in the jugular. But 
ordinarily the valve is insufficient from previous engorgement (or is 
congenitally so), or it becomes so from the distending action of the 
pulse, and then the pulse- wave passes into the internal jugular, and 
exceptionally also into its branches in the face. This systolic pulse 
must likewise be supposed to be propagated to a certain extent also in 
all other veins that are directly given off from the cava ; but they 
cannot be examined except in a large venous territory — the veins of 



228 SPECIAL DIAGNOSIS. 

the liver. Here the pulse manifests itself by a constant systolic 
swelling and diastolic collapse of the organ — the vejtous liver-pulse. 
Palpation of a liver thus constantly enlarged frequently shows the 
phenomenon of systolic venous pulse to a high degree. 

The systoHc jugular pulse may be graphically represented, as is 
shown in Fig. 8i. 

The mode of procedure in palpating the liver-pulse is as follows : One 
hand is placed upon the right hypochondrium or the epigastrium ; the 
other is passed around the chest at the level of the eleventh and 
twelfth ribs posteriorly. We can then feel that the organ is systol- 
ically enlarged, and thus we may avoid confounding it with Hfting up 
of the liver by the aorta or even with marked epigastric pulsation. 
Moreover, we recognize the liver-pulse in this way easier — that is, 
sooner — than by simply palpating in front. The liver is usually 
enlarged, almost always by the previously existing engorgement;^ at 
least, it immediately becomes so if tricuspid insufficiency occurs, as we 
very distinctly observed in a case of mitral insufficiency and stenosis, 
in which relative tricuspid insufficiency occurred, then subsided, and 
again reappeared. 

Arterial liver-pulse is exactly like venous liver-pulse in its phenomena 
(in aortic insufficiency).^ 

For the production of a recognizable venous liver-pulse, as well as 
a strong jugular pulse, there is, of course, required a certain moderate 
(and, if it has not been met with before, also it must not be too fre- 
quent) action of the heart. As the heart grows more and more weak 
the liver-pulse fails, and the jugular pulse gradually becomes smaller 
and more slow, until finally there is only a slight to-and-fro movement 
of the vein. 

In order to make a differential diagnosis of the different kinds of 
pulse in the veins of the neck it is necessary to bear in mind the fol- 
lowing: I. The transmitted pulse will be best distinguished from the 
positive real pulsation occurring at the same time with it by placing 
the finger or, better still, a pleximeter, with its edge in the middle of 
the neck, upon the vein : if the pulsation is communicated, it disap- 
pears in the central empty portion and becomes more distinct in the 
periphery from the engorgement of the distended portion ; on the 
other hand, a positive genuine pulse remains centrally unchanged. 2. 
The negative true pulse is distinguished from the positive and from the 
communicated pulsation generally by comparison with the apex-beat, 
as well as by comparison with the carotid pulse. (We seize the left 
carotid and at the same time observe the right jugular.) It is also 
to be observed that with the negative pulse the collapse of the vein is 
usually quick, and that it refills slowly. In this way, with a little 
practice, one can often immediately judge correctly. 

In order more exactly to observe and study these phenomena it is 
well to have the patient for a time breathe very superficially, or, if pos- 
sible, to hold the breath, so as to eliminate the respiratory to-and-fro 
swelling of the veins. 

We must still mention some occurrences that are extremely rare or 
are of very little diagnostic value : 

^ See Enlargement of the Liver. ^ See p. 221. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 229 

Diastolic collapse of the cervical veins (Friedreich), which looks 
very like systolic venous pulse, sometimes occurs in adhesive pericar- 
ditis and fibroid mediastinitis, and is connected with systolic drawing- 
in in the neighborhood of the heart, which occurs with this condition.^ 
The springing forward of the heart in the diastole, together with the 
forward movement of the anterior wall of the chest, probably produces 
an aspiration of the contents of the large veins. 

Systolic venous pulse may exceptionally occur with mitral insuf- 
ficiency and open foramen ovale : through the latter and the left 
ostium venosum the contraction of the left ventricle produces a recur- 
rent pulse-wave in the cavae and their nearest branches (very rare, being 
thus far only observed in one case). 

Double positive venous pulse (Leyden) is observed in hemisystole. 

3. Phenomena of Circulation in Other Veins. — Systolic true 
pulse may, as has already been mentioned, be propagated to the veins 
of the face, but this is rare. In individual cases it has even been ob- 
served in the cutaneous veins of the arm, in the small branches of the 
internal mammary (of which I have seen one case), in the vena cava 
inferior (Geigel), etc. 

The s,o-Q,-s^^^ progressive or ascending venous pulse (Quincke, Holz) 
has been seen in the veins of the hand and the back of the foot and 
in those of the forearm up to the elbow. This phenomenon may be 
met with in very different conditions : it seems to appear principally 
when the vessels of the extremities have a diminished tonus, the veins 
more or less full, and when the heart acts vigorously. Quincke has 
observed the ascending venous pulse in febrile states of every kind, in 
cerebral and spinal diseases, in chlorosis and anemia, finally in healthy 
subjects during hot weather. Holz and Senator have seen it in pseudo- 
leukemia and leukemia. 

Probably it can scarcely be explained otherwise than as an arterial 
pulse propagated through the capillaries ; but opinions still differ about 
the real conditions of its occurrence, and also as to its prognostic sig- 
nificance. As is evident from what has been said, as yet it cannot be 
turned to account diagnostically. 

4. Venous Thrombosis. — The transformation of the soft venous 
tubes into firm round cords that can be felt exhibits venous thrombosis. 
The thrombosed vein may often also be perceived by pressure. In 
internal medicine, of especial interest and importance is thrombosis of 
the large veins of the lower extremities as it sometimes occurs in the 
course of severe acute infectious diseases as the result of chronic in- 
validism, and in marasmus of the aged. Frequently, but never while 
resting in bed, it occurs in the edema of engorgement in the affected 
limb. 

// is important to touch such veins very carefully in order not to 
push off a piece of the thrombus. A piece torn off from the central 
end of the thrombus may be carried to the right ventricle, and from 
thence produce an embolism of the pulmonary artery. 

1 See pp. 176, 177. 



230 SPECIAL DIAGNOSIS. 



Auscultation of Veins. 

1. Sounds and murmurs of short duration are sometimes heard 
over the jugular and crural veins. 

In tricuspid insufficiency there is a systoHc recurrent blood-wave, 
which, by its impulse against the closing valve above the biilbus jugii- 
laris and against those in the crural vein at Poupart's ligament, and 
also by the sudden tension of the vein itself, causes a sound which will 
be heard by very lightly placing the stethoscope at these points. But 
a sound has also been heard where the crural valve was defective. In 
such cases it must be alone caused by the sudden tension of the venous 
tube. If these valves are insufficient, there may be a corresponding 
short murmur (very rare). 

The jugular sound generally accompanies the bulbar pulse of tri- 
cuspid insufficiency. A venous sound over the crural is, however, rare, 
because the recurrent wave only exceptionally reaches this vessel. 
Quite exceptionally with tricuspid insufficiency there may be a double 
sound over the crural vein, indicating first auricular, then ventricular, 
contraction (Friedreich). It can be distinguished with certainty from 
the sounds, double sounds, and murmurs of the crural artery only 
when there exist signs of aortic or tricuspid insufficiency (hence, how 
small is the diagnostic value of these phenomena !). Crural, arterial, 
and venous sounds may be combined when there exists at the same 
time aortic and tricuspid insufficiency. 

Now and then, even in health, especially in thin persons, a sound is 
produced over the crural vein by sudden straining or coughing (expira- 
tory valvular sound in the crural vein — Friedreich). 

2. A continuous murmur, designated as venous humming, venous 
m-urmttr, or buzzing, is often heard in anemic, and especially in chlo- 
rotic, patients, but sometimes also in many healthy persons, over the 
jugular veins. It is usually louder on the right side. It sounds like a 
regular humming or a very fine whizzing, or Hke the humming of a top. 
If it is very marked, it can also be felt. The murmur is caused by the 
whirl in the blood as it flows from the narrow jugular into its wider 
bulb. The whirls are the more marked the more rapid the stream, 
and hence the murmur becomes louder in deep inspiration ; and for the 
same reason it is generally louder in the upright position than when 
lying down. And likewise it is not infrequently louder in the diastole 
than in the systole of the heart. Also, the predominance of the right 
jugular over the left is explained by the difference in the rapidity of the 
current caused by the different shape of opening into the cava.^ This 
murmur will be increased by slight compression, as may be produced 
by the stethoscope or by turning the head to the opposite side. This 
latter effect comes from the tension o{ \.\i^ fascia colli, and probably also 
from the contraction of the omo-hyoideus muscle. 

As to what the occurrence of this murmur means, we must rest upon 
the old idea that it chiefly occurs with anemic, and especially chlorotic, 
patients. Friedreich's claim that it is more marked in these cases, while 
in health it is usually only to be heard as a soft humming, seems to me 

^ See above, p. 227. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 23 1 

to be very far fetched. Strictly speaking, no diagnostic importance is 
to be attached to this phenomenon. 

A similar murmur occurs exceptionally in other veins, and it is to 
be noted almost exclusively in anemia; thus, in the large veins of the 
extremities and also in the intrathoracic trunks. Here the murmur is 
always much stronger during the heart's diastole, and can thus appear 
to be interrupted. It has already been mentioned that Sahli declared 
the anemic heart-murmurs to be in part propagated from the venous 
trunks in the chest. 

EXAMINATION OF THE BLOOD. 

Preliminary Remarks. — We can only approximately determine 
the total amoiuit of blood in a healthy person. Its direct determination 
is of course impossible, and we are compelled to form approximate 
conclusions from animals. In mammals the quantity of the blood 
fluctuates considerably : it is between one-eleventh and one-twenty- 
third of the weight of the body. In dogs the variation is from one- 
€leventh to one-eighteenth of the weight. Of the quantity of the blood 
in diseased conditions we know from autopsies scarcely more than that 
it is diminished in a very conspicuous manner after severe hemorrhages 
and after the loss of large amounts of the water of the organism, as in 
cholera Asiatica and other severe diarrheas. But at the bedside we are 
still less able to estimate the quantity of the blood of the patient, even 
approximately. We certainly know that in genuine anemia from 
hemorrhage the color of the skin and of the mucous membranes 
becomes paler and the pulse smaller; but only under quite exceptional 
circumstances can we reason backward, vice vei'sd, from these signs to 
a diminution of the quantity of the blood, because paleness and weak- 
ness of the pulse may also be produced by disturbances of the circula- 
tion, and because paleness may be caused by a watery quality of the 
blood in itself — /. e. hydremia without anemia. 

Thus we know almost nothing of the quantity of the blood of the 
patient, and the conception '* anemia " has a very defective foundation. 
Apart from particular cases mentioned above, perhaps upon the whole 
it never exactly applies, because it has been proved experimentally that 
the blood in a high degree has the capability to balance a diminution 
of its quantity by quickly absorbing water. Nevertheless, if the expres- 
sion " anemia " is used, it is only because it has become naturalized. 
According to our present views it corresponds with the conceptions of 
hydremia, hypalbuminosis, diminished hemoglobin on the one hand, 
and diminution of the red cells on the other. It must be pointed out 
that the last-named state need not go quite parallel with the first- 
named. In respect to the so-called anemias, it is therefore of interest 
for the diagnostician to know in the first place the percentage of water 
and albumin, and particularly the percentage of hemoglobin — /. e. 
coloring-matter of the blood — and the number of red and white blood- 
cells. 

Besides, there are conditions in which the spectroscopical behavior of 
the blood is altered — conditions in which the form, size, and structure of 
the red and white cells are altered. There are also pathological admix- 



232 SPECIAL DIAGNOSIS. 

tures of different sorts, and finally certain less important chemical altera- 
tions, as, for instance, decreased alkalescence, etc. 

The examination of the blood must therefore include a number of 
points of view, but they do not all of them always come into consid- 
eration. Frequently we may be content with a very simple procedure, 
according to the result of which, and according to the remaining factors 
of the patient's condition, further investigations must be made. 

Anticipating somewhat, we here give a synopsis of the different 
steps in making examinations of the blood : 

1. The most simple procedure, which is often sufficient, and where 
it is not sufficient gives hints as to further examinations, is : determina- 
tion of the percentage of hemoglobin (Gowers-Sahli's hemoglobinometer) 
and inspection of a fresh microscopical preparation. 

2. A procedure which is sufficient for most pathological conditions 
of the blood : besides determining the amount of hemoglobin and the 
inspection of the fresh microscopical specimen, we are to count the red 
and white blood-cells and determine their proportion to each other. 
We are also to make and inspect an eosin-hemotoxylin preparation. 

To these there follow in succession : {a) either exhibition of Ehrlich's 
granulations and of the nuclear structure of the leucocytes ; {p) or, as 
may be necessary, other special methods, as, for instance, a study of 
the micro-organisms. 

Sometimes from the beginning we have only to examine for micro- 
organisms (recurrens [spirillum of relapsing fever], anthrax, etc.) ; 
sometimes the attention is principally directed to the spectroscopic 
quality of the blood (certain cases of poisoning), etc. These details 
will become clear from what follows. 

Regarding the value of centrifuging the blood by means of the 
hematocrit we have no basis for a personal opinion, though we doubt 
whether the method will have a lasting value for the diagnostician. 

The methods of obtaining blood differ according to whether a 
smaller or larger quantity is desired. For most purposes it is suf- 
ficient to obtain the blood by a puncture in the tip of the finger or lobe 
of the ear. After having used it for many years, we can most strongly 
recommend the scarificator devised by Francke (made by Katsch in 
Munich), and we particularly emphasize these points in regard to it : it 
can be easily disinfected ; it can be used for the smallest punctures ; 
it can be so arranged that only the fine point of the lancet pene- 
trates the skin. A particular advantage we found in the fact that, 
instead of using the finger-tip or lobe of the ear, we may use a place a 
very little larger, and may obtain the drop of blood at a place less rich 
in blood-vessels, as somewhere on the arm. This is in every respect a 
better place. If a larger quantity of blood is required, as is desirable 
in making cultures and is indispensable for quantitative chemical analy- 
sis, we recommend the very simple and perfectly safe method which v. 
Ziemssen has recommended, which consists in removing the blood by 
aspirating the median vein.^ 

I. Color (Amount of Hemoglobin) ; Spectroscopic Character 
of the Blood ; Density of the Blood.— Blood taken directly from a 
healthy person is of a recognized color : if arterial, it is brighter, rich in 

1 See p. 251. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 233 

oxygen — that is, rich in oxyhemoglobin ; if venous, it is darker, bluish- 
red — that is, it is poor in oxygen. The marked deficiency of oxygen in 
the blood of a person suffering from dyspnea or venous engorgement, 
or both, makes the blood very dark. In carbonic-acid poisoning the 
blood is bright cherry-red ; from chlorate of potash, anilin ; and in 
severe poisoning by hydrocyanic acid and nitrobenzol it is brownish- 
red or chocolate color. In severe anemia and chlorosis (hydremia) the 
blood is watery ; in marked leukemia it looks a peculiar whitish-red, as 
if mixed with milk, or chocolate color. 

These changes in the color of the blood all have an effect upon the 
color of the patient's skin, as has already partly been mentioned. 
Hence patients with carbonic-acid poisoning look strikingly rosy, while 
in poisoning with chlorate of potash, anilin, and nitrobenzol the skin 
and mucous membrane are a peculiar grayish-blue or black color. 
These discolorations of the skin, as well as the differences in the color 
of a drop of blood obtained by pricking with a needle, have too little 
distinction to be directly of diagnostic use. But, especially with regard 
to the poisons that have been mentioned, if they are recognized as 
unusual, they demand that a timely and thorough examination of the 
blood be made by the spectroscope or microscope. In this lies the 
great value of a knowledge of these discolorations. 

For recognizing heinoglobineniia (from the hemoglobin that appears 
in solution in the serum of the blood originating from the red blood- 
corpuscles) it is necessary to employ a wet cupping-glass, or to take 
blood from a vein after the method of v. Ziemssen. The blood thus 
withdrawn is allowed to stand covered for twenty-four hours, if pos- 
sible in an ice-chest, and then the serum, separated from the coagu- 
lum, is to be examined. That from normal blood is yellow, in hemo- 
globinemia it is rubine-red, and in the spectroscope gives the bands of 
oxyhemoglobin.^ 

Approximative Determination of the Amount of Hemoglobin. — A dim- 
inution in the amount of the hemoglobin may be conditioned upon a 
diminished number of red corpuscles or upon a decrease in the amount 
in single corpuscles, or upon both.^ The color of the skin is a very 
unsafe index of the percentage of hemoglobin in the blood. The color 
of the mucosae also is often misleading, but in any case is always a 
very inexact index, for reasons we have already pointed out. There- 
fore, lately reliance is more and more placed on the examination of the 
blood itself In extreme anemia the drop of blood which exudes from 
a wound made by a needle-puncture on the finger appears distinctly 
pale to the practised eye, and enables it to recognize without doubt a 
diminished percentage of hemoglobin. To make possible, however, 
the judging by the eye of the percentage of hemoglobin in a drop of 
blood, even in slighter variations from the normal, technical aids are 
absolutely necessary. Of late there have been constructed to this end 
a number of instruments. We mention here only two, which we most 
strongly recommend; Fleischl's hemometer and Gowers's hemoglobin- 
ometer. Both of them possess by no means absolute exactness, but are 
sufficiently accurate for the purposes of practice, and are comparatively 
simple and quick in giving results. Formerly we always used only 

^ See below, p. 236. ^ See below. 



234 SPECIAL DIAGNOSIS. 

Fleischl's instrument, but lately, in consequence of the earnest recom- 
mendation of Sahli, we have frequently used also the much cheaper 
and still more simple instrument of Gowers. We recommend the 
latter instrument to every practitioner for widest use in diagnosis of 
anemia and determining its degree. The principle of the hemometer of 
Fleischl is as follows : 

A certain very small quantity of blood (obtained by a prick of a 
fine lancet, or, better, by means of a [Francke] scarificator), is thinned 
by a definite quantity of water, and then by lamp or gaslight the color 
of this mixture is compared with the color of a glass wedge which 
has been colored with Cassius's gold purple and carries a movable 
scale. Upon this scale the figure lOO corresponds with the intensity 
of color of a mixture of normal blood. Material that has less inten- 
sity has the numbers 90, 80, etc., down to 10, thus giving directly 
the percentage relation of the mixture of blood that is being exam- 
ined to that of normal blood with reference to the quantity of hemo- 
globin. Thus, 50 indicates, if the mixture of blood has been properly 
prepared and corresponds in color with the color of the glass wedge 
at that point of the scale, that this blood contains only 50 per cent. 
of the normal quantity of hemoglobin. 

This instrument gives inexact results, varying in extent with dif- 
ferent specimens, but, except when the amount of hemoglobin is greatly 
diminished, the inexactness is not sufficiently marked to vitiate the 
conclusions. Dehio gives the following table of variations with his 
instrument. (The findings were too small by the amounts represented 
by the figures in the second column.) 

With 90 per cent, of hemoglobin 0.4 

With 70 " " 2.8 

With 50 " " 4.5 

With 20 " " 5.5 

The principle of Gowers's instrument is similar : it is to determine 
how much a certain very small quantity of blood must be diluted to 
have the mixture agree in intensity of color with a normal solution, 
which consists of picric acid and carmin in glycerin. This solution, 
however, can be used only for comparison in daylight. For use in 
artificial light Sahli has made another solution which he calls " normal 
solution to Gowers's hemoglobinometer." (It is sold by the optician 
Hotz in Berne.) Water is used as the diluent for the blood. 

Method of Using Gowers s Hemoglobinometer. — A small wooden 
block forms a stand for the tubes b and c (see Fig. 82). The tube b is 
closed and contains the test liquid, picric-acid-carmin solution. The 
tube c is open at the top and serves for the reception of the blood-mix- 
ture which is to be examined. On this tube is a scale which gives 
the percentage of hemoglobin in the blood which is being examined, 
compared with the percentage of hemoglobin in normal blood. Into 
the little tube c are put a few drops of water to immediately dissolve 
the blood as it is poured into it. Then a puncture is made with 
Katsch's scarificator according to the method given above, and, as the 
blood exudes, by means of the sucking pipette it is slowly sucked up 
to a mark on this pipette. The point of the pipette is now to be 



EXAMINATION OF THE CIRCULATORY APPARATUS. 



235 




Fig. 82. — Gowers's hemoglobin- 
ometer (after Rieder). 



quickly wiped, and then its contents squirted directly into the water 
which is at the bottom of the tube c. Several times the pipette is to 
be refilled with water and emptied into the 
tube c, in order not to lose any blood on 
its capillary wall. The pipette itself may 
be used for stirring the mixture in the tube 
c if care is taken to completely empty it so 
as not to lose anything adhering to it. 

Water is now slowly added to the tube 
c, by means of the pipette, till its contents 
correspond in color exactly with the color 
solution in the tube b. It is best to hold the 
tubes against a white surface. When the 
two tubes have been made to correspond 
exactly in color, the number up to which 
c is filled is read off. The number 100 rep- 
resents the normal percentage of hemo- 
globin in the human blood. If the liquid 
stands at 40, for instance, it means that the 
percentage of hemoglobin in the examined 
blood is in proportion of 40 to 1 00 to that of the normal blood; that 
is, the examined blood contains only 40 per cent, of the normal quan- 
tity of hemoglobin. 

From this can be calculated the absolute percentage of hemoglobin 

in the specimen of blood by putting at 14 per cent, the percentage of 

hemoglobin in normal blood. The examined blood contains, then, in 

40 X 14 ^ - , ... 

100 grams — 5-o g. ot nemoglobm. 

The average limit of error of this instrument is very small : Rieder 
gives it as 3 per cent. Since its contents become pale with the lapse 
of time, the test-tube b must be renewed from time to time, or it must 
be controlled by a solution of normal blood which has been diluted to 
100. This is not the place to speak of the more exact methods of 
determining the percentage of hemoglobin. We refer to works upon 
physiology. 

Spectroscopic Character of the Blood. — In certain cases its examina- 
tion has decided significance. Recently it has been rendered very 
much more easy by very practical clinical and uncomplicated apparatus, 
of which we may mention the spectroscope devised by Desaga (Heidel- 
berg), and still more recently Hering's very cheap spectroscope without 
lenses. The latter, after a little practice, is entirely satisfactory for 
clinical purposes. The blood or the blood-serum, having been diluted 
with water, is held in a test-tube before the slit of the instrument and 
examined against a white light. 

In three classes of cases the spectroscopic examination of the blood 
gives a valuable result ; in Jicinoglobinemia there is no doubt about 
the presence of the coloring-matter of the blood in the serum ^ if the 
serum shows the absorption-band of oxyhemoglobin ; one in yellow 
near green (close to D, Frauenhofer), and one in green near the former, 
between D and E. Moreover, in carbonic-oxid poisoning there appear 

1 See p. 232. 



236 



SPECIAL DIAGNOSIS. 



in the blood two absorption-bands which are very near the two above 
mentioned, only a little nearer the violet Hne, and hence they may be 
confounded with them, but they are very distinctly separated from 
bands of oxyhemoglobin in that they do not disappear on the addition 
of ammonium sulphate (since . carbonic oxyhemoglobin is not thus 
reduced). 

Lastly, it has recently been discovered that in poisoning with chlo- 
rate of potash, methemoglobin occurs in the blood in the living organ- 
ism. In acid and neutral solutions this causes an absorption-band in 
yellow (between C and D), besides three others more faint, which coin- 
cide with that of hematin, but which are distinguished from it in that 



^, 



v. 



X 



1- 


...1 ^^^ 





„nf,inln. 


B " 


El 

'ud'i"' 




r 

liu. 


f im 












1 










i 


























1 








11 








































1 


i 




























































































II 


1 i 








Ill 





Fig. 83. — Spectrum absorption-bands of the coloring-matter of the blood and its derivatives 

(after Rieder). 

upon the addition of ammonium sulphate it first gives place to the 
absorption-bands of oxyhemoglobin, then to that of O-free hemoglobin 
(a broader band from D almost to E in green and yellow). In alkahne 
solution methemoglobin shows a narrow band in yellow near to D, 
and one in yellow-green and green. 

There are still other changes in the blood, partly relating to its 
color and partly relating to its behavior in the spectrum, when animals 
are poisoned, but they do not seem to require special mention in this 
book. 

Determination of the Consistence of the Blood, ^r its Specific Gravity. — 
In recent years different methods have been devised by v. Jaksch, 
Hammerschlag, and Schmaltz. We must abstain from a criticism of 
them, as we have not made any comparative investigations with them. 
But we can say of them all that they are superfluous for diagnostic 
purposes, since Schmaltz found that the specific gravity of the blood is 
almost exclusively determined by the percentage of hemoglobin ; at all 
events, it goes parallel with it. The determination of the density of 
the blood can, therefore, be replaced for clinical purposes by the much 
more simple and comparatively more exact determination of the hemo- 
globin. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 237 

Z, Microscopic Examination of the Blood. — The normally 
formed constituents of the blood are, as is well known, the red and 
white blood-corpuscles and blood-plates. The morbid conditions of 
the blood which can be recognized by the microscope may be divided 
as follows : 

Alterations in the number of the red and of white corpuscles, or varia- 
tions in the numerical proportion of these two components of the 
blood. 

Abnormal size, and form, and peculiarities of the structure of the red 
cells. 

Abnormal quality of the white cells. 

Admixtures : These, in the first place, are products of decompo- 
sition from the blood itself, and micro-organisms. 

About some of these points the fresh, unstained preparation gives 
explanation ; others, and especially the quality of the white cells and 
most of the micro-organisms, can only be recognized in stained dry 
preparations. 

Mode of Procedure. — For the purpose of making a fresh, unstained 
blood-preparation there are required object-glasses and cover-glasses, 
cleaned as thoroughly as possible. If they are cold, they must be 
warmed a little. Then the place of puncture^ must be washed with 
water or a fresh \ per cent, solution of table salt, and then wiped dry. 
A puncture is made with a clean needle or with the extreme point of 
Francke's scarificator.^ The blood which first escapes is to be wiped 
off, and that which flows afterward is removed with a cover-glass, which 
is to be immediately dropped upon the object-glass held in readiness, or 
a drop is received on the object-glass and covered quickly with the 
cover-glass without any pressure. It is not advisable to promote the 
flow of blood by pressure on the parts surrounding the place of 
puncture. The examination must be made at once, because the red 
blood-corpuscles, as well as the white, after a short time are subject to 
alterations. Spots at the edge of the preparation or in the neighbor- 
hood of air-bubbles are not to be studied, because here the red cells 
shrink and decompose. For the purpose of demonstration the prep- 
aration can be preserved for a brief time by encircling it with oil. 

Counting the Blood-cells. — When one wishes to count the red and 
white cells a somewhat larger puncture is required. Francke's scari- 
ficator, with its lancet arranged so that it comes out one-half its length, 
is particularly useful here, but in this way a sufficient drop of blood 
can be gotten from the arm or the ball of the little finger. 

Making Dry Preparations. — For this purpose only fine punctures 
are needed, also very thin, somewhat larger, new cover-glasses, which 
immediately before being used are to be cleansed with water, alcohol, 
and ether, and well dried. Take one of them between the thumb and 
forefinger of each hand ; take up with the edge of one some freshly 
upwelling blood and spread it over the other in the finest possible 
layer, or pass the other quickly across the spot of the first, which is 
moistened by the blood. 

Microscopical Examination for Micro-organisms. — For this purpose a 
particularly careful cleansing of the place of puncture and of the 

^ See above. 2 gee p. 232. 



238 SPECIAL DIAGNOSIS. 

glasses is necessary. Strict antisepsis and asepsis is, however, of 
course, only necessary if the blood is to be used for making cultures. 

1. Alterations in the Number and Appearance of the Red Blood- 
corpuscles. — These are ascertained on the fresh, unstained prepara- 
tions. A counting-apparatus is required for counting them. The one 
by far most to be recommended is that of Thoma-Zeiss.^ 

A cubic millimeter of blood from a man normally contains about 
5,000,000 red blood-corpuscles; from a woman there are 4,500,000 
(C. Vierordt, Laache). A morbid diminution observed in a single 
examination of a case could only be positively asserted if the enumera- 
tion showed one-half of this number or less. The smallest quantity 
found in disease is about 400,000 to the cubic millimeter. 

Oligocythemia is a diminution of the red cells if the whole quantity 
of blood is taken as the unit of measure. This is the alteration of the 
blood which accompanies the different forms of anemia [hydremia), of 
pernicious a^iemia, and leukemia. Exactly parallel with this may be an 
alteration in the percentage of hemoglobin ; but a complete parallelism 
may also be absent here, for in pernicious anemia the number of 
blood-corpuscles is certainly diminished, but the percentage of hemo- 
globin is greater,^ and therefore the whole blood contains, it is true^ 
Httle hemoglobin, but more than would be expected according to the 
existing ohgocythemia. Conversely, in chlorosis the percentage of 
hemoglobin is much diminished, as has been mentioned before, but 
there is no, or very little, oligocythemia, because in this disease there 
exists essentially an impoverishment in respect to hemoglobin. 

Counting the Blood-corpuscles. — In anemia, in a stricter sense, it has 
a diagnostic value, but it has even greater value in that it enables one 
to recognize the course of an anemia — its improvement or deterioration 
— and this, after what has already been said in the introduction, forms 
its diagnostic value in a wider sense. But, as follows from what has 
been said above, since in chlorosis the number of the red cells has to 
be considered only a little, and since in common anemias there exists 
usually also during the course of the disease a certain parallehsm 
between the number of blood-corpuscles and the percentage of hemo- 
globin, we may say that in chlorosis and simple anemias for determin- 
ing the course of the disease it is generally sufficient to control the 
percentage of hemoglobin, which requires less time and trouble than 
counting the cells. 

Method of Counting. — The Thoma-Zeiss apparatus for counting 
the number of corpuscles is the best of all those now in use.^ It 
consists of a mixer and a Hayem's counting-chamber. 

The mixer serves to distribute the blood in as equal a manner as 
possible — a very important point. For thinning the blood a 3 per cent, 
solution of salt is recommended. The mixer is a kind of measuring- 
pipette with a very fine canal and with a spherical enlargement con- 
taining a little glass ball. The portion of the tube below the cavity has 
the marks 0.5 and i.o. Just above the cavity is the mark lOi. The 

^ See below. ^ See below. 

^ Miescher has lately made some alterations in this apparatus which are calculated to 
increase the accuracy in counting. I have not yet had the opportunity to test the instrument 
in its new form. It is to be obtained of Karl Zeiss in Jena : Melangeur after Miescher. 



EXAMINATION OF THE CIRCUIATORY APPARATUS. 239 

first two marks are those to which the blood, directly after it has been 
drawn from the finger, is sucked. If we wish a mixture of I to 200, 
we draw it up to 0.5 ; if a mixture of i to 100, to i.o. In both cases 
we wash off the blood clinging to the point and draw in a 3 per cent, 
solution of salt, or Hayem's fluid, to loi. Then the mixer is shaken 
several times, so that the glass ball equally mixes the contents. We 
next expel the contents of the fine tube, which consist of salt solution 
or Hayem's fluid, after which we fill from the mixture a Hayem's 
counting-chamber. This consists of an object-glass with a circular 
excavation ; it is a space exactly -^-^ mm. deep, the floor of which is 
divided into microscopic squares whose sides are 2V "^"^- ^ong. The 
cubic capacity of the space over each square is 2V ^ 2V ^ tV c-^nm. = 
ToVoC.mm. 

Hayem's fluid \?,'. hydrarg-bichlorid, 0.5; sodii sulphat., 5.0; sodii 
chlorid., 2.0; aquae destil., 200.0. 

Into this cavity some of the blood-mixture is blown, and then 
covered with a glass cover after carefully expelling any air-bubbles. 

After waiting a moment, in order that the blood-corpuscles as far 
as possible may equally distribute themselves, we magnify it about 50 
diameters, and count the number of corpuscles in the larger number 
of the above-named squares, and thus obtain an average of the con- 
tents of, say, sixteen of them. The oftener these sixteen squares are 
counted the greater will be the accuracy of the result. We can calcu- 
late the number of corpuscles in a cubic millimeter from the proportions 
of the mixture and the cubic contents of the squares, as given above. 

Immediately after use the mixer must be most carefully washed 
with water, alcohol, and ether, and it is best to afterward dry it with 
the air-bellows. 

The proportion between the quantity of red cells and the percentage 
of hemoglobin in the blood is, however, by no means constant, because 
the percentage of hemoglobin in the individual blood-corpuscles varies 
in different morbid conditions. This is of diagnostic importance. 
Here are opposed to each other in a pronounced degree chlorosis and 
so-called idiopathic or pernicious anemia. 

In chlorosis there is a markedly diminished percentage of hemo- 
globin of the blood, with a slight, or at least proportionately slight, 
diminution in the number of red corpuscles. The individual cells are 
even poorer in hemoglobin, as occurs in chlorosis of a high degree in 
the ordinary fresh microscopic blood-preparation. Dehio has lately 
found a similar behavior of the blood also in phthisical and carcinom- 
atous cachexia and in the anemia of beginning secondary syphilis 
(formerly called syphihtic chlorosis), but the investigations of Sadler 
contradict this. 

On the contrary, in pernicious anemia the percentage of hemoglobin 
is less diminished ; the number of red cells, and particularly their whole 
volume, are more diminished. For this reason the remaining cells are 
extremely rich in hemoglobin. On the other hand, Dehio found 
closely similar to this form the anemia caused by the bothriocephalus 
latus,^ which also otherwise shows similarities to pernicious anemia or 
may even change into it. 

^ See below. 



240 SPECIAL DIAGNOSIS. 

2. Alterations in the Size and Form of the Red Corpuscles.^ — 

Red cells reduced in size, enlarged, and abnormally shaped may be 
observed — microcytcs, macrocytes, poikilocytes. On all the cells absence 
of the depression is noticed. 

These changes, combined with a decrease in the number of the red 
corpuscles, and at the same time a normal condition of the white cor- 
puscles, constitute the condition of the blood of so-called pernicious 
anemia. However, it must here be remarked that lately this is not 
regarded as a simple disease in itself, since we have learned to recog- 
nize it in many cases as a secondary state following different influences 
very injurious to the body. We shall return to this subject again a 
little later on. 

The simplest way of determining the size is to compare a prepa- 
ration of blood with that of a healthy person (the examiner himself). 
The normal diameter of red blood-corpuscles is 7.7 to 8/>< [/. e. about 
¥300 of an inch]. 

Microcythemia. — By this we understand the occurrence of forms 
containing hemoglobin, which are smaller than red blood-corpuscles, in 
which the form is nearly or quite perfect, or, if they are very small, 
they are simply globular, and then are always very rich in hemoglobin. 
We see the former in the new formations of blood after hemorrhages 
and also in all kinds of anemia. They are probably young red cor- 
puscles. The latter — microcytes, strictly so called — occur especially 
frequently in genuine pernicious anemia, and also in all severe second- 
ary forms of anemia. The supposition that they are sometimes formed 
upon the glass slide is possibly correct, because they may even be 
found in normal blood if the preparation contains air or if it has been 
pressed, or also if it has not been freshly made. I have never seen 
them when examining a perfectly fresh, otherwise normal, preparation 
of blood, except at the border (the effect of air). 

Macrocytes — abnormally large red corpuscles — besides those of 
normal size and very small ones — occur in individual cases of marked 
and simple anemia, but especially in pernicious anemia. This disease 
must always be suspected when they are present. Moreover, very 
often the poikilocytes to be described below are larger than normal 
[red corpuscles]. 

Nucleus-containing macrocytes {^gigantoblasts — Ehrlich) seem to be 
the surest sign of a degradation of the blood-making organs and also 
of pernicious anemia. However, it is to be remembered that, accord- 
ing to our present knowledge, the alterations of the blood in pernicious 
anemia may occur secondarily to grave injuries of the organism. 

Poikilocytes^ strictly speaking, are red corpuscles changed in form. 
They may assume the greatest variety of forms : club, biscuit, pear, 
flask, and drumstick are the most usual forms. In many ways 
poikilocytes correspond to enlarged red corpuscles. In individual 
cases they exhibit ameboid movements. In a wider sense we employ 
the expression poikilocytosis for a mixture of such forms with micro- 
cytes and macrocytes, which are almost always present. 

We must avoid confounding with them the mulberry and thorn- 
apple forms, which occur normally, or mechanical or chemical prod- 

1 Compare Fig. 84, p. 241. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 



241 



ucts, by using the greatest care in making the preparations and then 
immediately examining them. 

Poikilocytosis, strictly speaking, is not at all in itself a pathognomonic 
symptom of pernicious anemia, although in other forms of anemia it 
does not occur so regularly and in so marked a degree as in pernicious 
anemia. For a diagnosis of pernicious anemia there is necessary the 
presence of both macrocytes and gigantoblasts (see Fig. 84). As a 






\ 



# ^\ 



%% 










% 



qO 



o 



' o 

#1 ^ n ,-. 



Fig. 84. — Progressive pernicious anemia ; 
magnified 300X. Dry preparation, eosin- 
hemoglobin. The red blood-corpuscles all 
without umbilicus. .Macrocytes, microcytes, 
shadows, poikilocytes, two megaloblasts, two 
normoblasts, one lymphocyte (from Rieder's 
At/us). 



Fig. 85. — Primary anemia gravis ; mag- 
nified 300X. Dry preparation, eosin-methyl- 
ene-blue. All the red cells have the umbilicus. 
Macrocytes, microcytes, poikilocytes (from 
Rieder's Atlas). 



distinction from pernicious anemia some call the severe anemia without 
the presence of megaloblasts "anemia gravis " (see Fig. 85). Pernicious 
anemia is, however, by no means always an independent disease. On 
the contrary, it has been ■ observed in connection with tapeworm (espe- 
cially bothriocephalus latus), with severe leukorrhea, in carcinomatous 
cachexia, after exhausting hemorrhage from the stomach, and in 
pregnancy. 

As a matter of course, all these changes in the red corpuscles 
usually very notably accompany diminution in their number and of 
the amount of hemoglobin. Hence, as has already been mentioned, 
the amount of hemoglobin in single blood-corpuscles is not infrequently 
increased. 

(Regarding defects within the red corpuscles, which appear in acute 
infectious diseases and severe anemias, and may be mistaken for 
malarial parasites, compare under the latter.) 

In order to make visible tJie nuclei of the red blood-corpuscles a 
fixed dry preparation is stained with eosin-carbol-glycerin, and after- 
ward quickly stained with hematoxylin. The method is the same as 
that employed to bring out the eosinophile white cells. The bodies of 
the red blood-cells containing the nucleus often appear to have taken 
up the eosin remarkably strongly. 

3. Normal and Pathological Condition of the White Blood- 

16 



242 SPECIAL DIAGNOSIS. 

cells. — The proportion of white corpuscles to the red in normal blood 
drawn by a puncture, according to the older examinations, was, on the 
average, from i to 400 up to i to 700. According to v. Limbeck, 
more exactly it is as i to 555 up to i to 625. That is, in a cubic 
millimeter of blood there are about 8000 to 9000 leukocytes. The 
white cells of normal blood exhibit different forms : {a) mononuclear, 
partly very small (z. e. approaching the red cells in size), cells with so- 
called basophil-granulation of the body (" lymphocytes ") ; {h) polynu- 
clear cells with polymorphic nuclei or with several separated, strongly 
tingeable nuclei, and finely granulated bodies with neutrophilous granu- 
lations ; (c) coarsely granulated cells with eosinophile granulations and 
weakly tingeable, often with multiple nuclei ("eosinophile cells"), the 
latter in very varying number; (^) now and then *' mast-cells." 

An alteration in the proportion of the red and the white cells in 
favor of the latter indicates either leukocytosis or leukemia. 

In leukocytosis the increase of the white blood-cells is more or less 
temporary and slight in amount. All the forms of the white cells are 
increased or only the polynuclear neutrophile ones. The latter is 
particularly the case in the " inflammatory " and in the '' cachectic " 
leukocytosis.^ 

Leukocytosis occurs physiologically during digestion. There is also 
a so-called " inflammatory " form in acute infectious diseases, particu- 
larly in those which are distinguished by the formation of large exuda- 
tions rich in cells, like pneumonia, but also in erysipelas, pleurisy, and 
peritonitis. In typhus abdominalis [typhoid fever], however, not only 
is there no leukocytosis, but, on the contrary, there is a diminution 
of the white cells. The name inflammatory leukocytosis may also be 
given to that form which is caused by the swelling of lymphatic glands 
in all kinds of local inflammation. Finally, there is to be mentioned 
the cachectic or hydremic leukocytosis occurring in all forms of anemia. 
This may be a relative leukocytosis, caused by diminution of the red 
blood-corpuscles, but also an absolute condition, as has been proved 
by enumeration of the cells. In the latter case it is probably to be 
explained by the acceleration of the lymph-current, which no doubt 
exists in consequence of the hydremia. 

According to the investigations of v. Jaksch, it appears at least as 
probable that the number of leukocytes has a prognostic value in pneu- 
monia : he found the inflammatory leukocytosis absent in severe, badly 
progressing cases. 

Leukemia is usually very easily microscopically distinguished from 
leukocytosis, because in this condition, in well-developed cases, there 
is a much more considerable increase of the white cells : most frequently 
there is approximately one white to ten red cells, but in the highest 
degree the proportion is about one to one. 

But in slighter degrees or at the beginning leukemia, especially the 
myelogenous and lienal-myelogenous forms, may be positively recog- 
nized on the basis of Ehrlich's observations. The early diagnosis of 
lymphatic leukemia, and particularly its distinction from leukocytosis, 
is certainly more difficult. 

In myelogenous and lienal-7nyeloge7tous leukemia there are found in 

1 Compare Fig. 87, p. 243. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 



243 



the blood: {a) one-sidedly increased eosinophile cells — the compara- 
tively least safe sign, because an increase of this formation occurs else- 
where, even in health, particularly in infancy : large eosinophile cells 




Fig. 86.— Normal blood. Magnified 
300X. Dry preparation, eosin-hemato.xylin. 
In the field of vision a lymphocyte, a poly- 
nuclear cell, and an eosinophile one. The 
nuclei of all the white cells dark blue, the 
eosinophile granulations a brilliant red (from 
Rieder's Atlas). 



Fig. 87. — Inflammatory leukocytosis ; 
magnified 300X. Dry preparation, Aronsohn- 
Phillips's staining (see page 245). Marked in- 
crease of polynuclear leukocytes. Repre- 
sentation of their neutrophile granules (from 
Rieder's Atlas). 




Fig. 88. — Lienal-rriyelogic leukemia ; 
magnified 300X. Dry preparation, eosin- 
hematoxylin. Most of the white cells are 
uninuclear ; many are strikingly large, with 
large plump nucleus. Several eosinophile 
cells. One nucleus contains red blood-cor- 
puscles (from Rieder's Atlas). 



Fig. 89. — Lymphatic leukemia; magni- 
fied 300X. Dry preparation, eosin-hema- 
toxylin. Almost all the white blood-corpuscles 
uninuclear (lymphocytes) ; most of them very 
small (from Rieder's Atlas). 



(marrow-cells) seem, however, only to occur in leukemia; {B) very 
large mononuclear cells, much larger than those of normal blood, and 
in contrast to those filled with neutrophile granulation-material; (c) 
sometimes abundant " mast-cells," a cell-form which occurs only very 



244 SPECIAL DIAGNOSIS. 

rarely in normal blood; (<i) nucleus-containing red blood-corpuscles, 
as large or larger than normal (megaloblasts) ^ (compare Fig. '^'^). 

In lympJiatic leukemia^ however, there is one-sided increase of the 
lymphocytes. Thus this form, in slight cases, is similar to leukocyto- 
sis, although to the latter belongs either an equal increase of the dif- 
ferent forms or an increase of polynuclear neutrophile cells (compare 
Fig. 89). 

Moreover, in leukemia the number of red blood-corpuscles is prob- 
ably always diminished : v. Jaksch found in making an average of 
several cases that there are 2,000,000 to 3,000,000 of cells (red and 
white) to the cubic millimeter. 

It is to be mentioned that in leukemia the red blood-corpuscles not 
infrequently show all the signs of poikilocytosis. 

A very rare finding in leukemic blood are Charcot's crystals (prob- 
ably identical with those of the sputum ^ and feces). 

Methods of Counting the White Blood-corpuscles. — For sucking up 
the fresh blood we employ a mixer having the proportion of i : 10 
or of I : 20 (made by Zeiss of Jena). The diluting liquid is a 3 per 
cent, acetic acid, which dissolves the red blood-corpuscles. If the 
red blood-cells have already been determined, the proportion of 
the white to the red can be quickly calculated. In leukemic blood 
this proportional number of the white to the red corpuscles may also 
be obtained by diluting the blood with a i per cent, solution of sodium 
chlorid to which is added some watery solution of gentian-violet. The 
red and the white corpuscles can then be counted together. 

Miescher recently suggested an improved blood-mixer which gives 
greater exactness in counting the cells (also to be obtained from Zeiss 
in Jena). 

Method of Drying Blood-preparations. — First make very thin cover- 
glass preparations, and allow them to dry in the air, protected from 
dust by a bell-glass, or in damp weather in the exsiccator. Then 
they are fixed either by gradual heating for ten to twelve hours in the 
drying chamber or on a copper plate at 1 10-120° C, followed by slow 
cooling or by putting them for two hours in equal parts of ether and 
absolute alcohol. If there is need for haste in forming a preliminary 
opinion, the air-dried preparation may be passed through the flame of 
a lamp six to ten times. 

Method of Staining to Show the Different Cell-forms. — i. Simple 
Staining to Demonstrate the Esinophile-granidations and the Nuclei 
of White and of Red Blood-corpuscles. — The dry preparation is to be 
stained for several hours with a few drops of saturated solution of 
eosin (bluish, Marke 22, v. Beyer-Elberfeld) in 5 per cent, carbolic- 
glycerin, rinsing or washing out in water, and restaining with methyl- 
ene-blue or hematoxylin. In the latter case we use, for a few minutes, 
Bohmer's or Delafield's solution, diluted with equal parts of water, 
rinsing in water, drying in the air or in moderate warmth, then sealing 
up in the usual way. Rieder has even demonstrated mitoses by this 
method. 

2. Demonstration of the Basophile, Neutrophile, and also of the Mast- 
cell Granidations. — (a) The basophile or ^-granulation of mononuclear 

1 See above, p. 241. ^ Compare p. 157. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 245 

cells (lymphocytes) for several minutes is stained with a concentrated 
watery solution of methylene-blue. (The solution must always be 
freshly filtered.) 

{B) For staining the neutrophile or e-granulation of the common 
" finely granulated " polynuclear cells we, as well as others, have found 
Aronsohn-Phillips's modification of the mixture given by Ehrlich to be 
reliable: a mixture of saturated solution of orange-G extra and crystal- 
lized methyl-green extra, after they have been well sedimented, in the 
following proportions : • ' 

Solution of orange, 55-0; 

Solution of acid fuchsin, 50.0 ; 

Aq. destillat., lOO.O; 

Absolute alcohol, 50-0; 

to which is to be added — 

Solution of methyl-green, 65.0; 

Aq. destillat., 50.0; 

Absolute alcohol, 12.0. 

(This is effective after standing one to two weeks ; some time later it is 
less effective again.) The specimens are to be stained for several 
hours, and then washed out with water, the duration being determined 
by repeated inspection of the moist preparations ; then they are dried, 
etc. 

(r) The mast-cell granulation is very well stained with Ehrlich's satu- 
rated solution of — 

Dahlia in absolute alcohol, 50.0; 

Aq. destillat, loo.o; 

Acid, acetic, glacial., 12.5. 

It is to be stained for several hours, rinsed with water, and washed out 
with alcohol for a still longer time, rinsed with water, etc. 

4. Abnormal Additions to the Blood.— Of these we first mention 
melanemia and lipemia. 

Melanemia occurs directly after severe attacks of malaria and in- 
malarial disease. We sometimes find, swimming free in the blood, 
brownish-black or yellow-brown lumps and granules, or also white 
blood-corpuscles filled with such granules. They result from breaking 
up of red corpuscles. 

By lipemia we understand the occurrence of extremely fine drops of 
fat in the blood, as in drunkards, in diabetes, and in chyluria, but they 
are also sometimes seen in health. 

In recent times we have learned to recognize 7nicro-organisms as most 
important additions to human blood. They are exclusively schizomy- 
cetes. 

About making cover-glass preparations for examinations of micro- 
organisms, compare page 247. For making cultures it is recom- 
mended, in taking blood, to make larger punctures or to take blood 



246 



SPECIAL DIAGNOSIS. 




from a vein in which the flow of blood has been stopped (v. Ziemssen) 
(compare page 251). 

Anthrax bacilli in the blood have been repeatedly found in infection 

by anthrax, although always only in 
moderate quantity. The defect in the 
microscopical proof does not exclude, 
however, a general infection : a test by 
inoculating mice may, however, succeed. 
We may often have single bacilli of 
anthrax occurring together, not threads ; 
spores may be entirely wanting. The 
bacilli are recognized, without staining, 
as tolerably thick rods, as long as, or 
twice the diameter of, a red blood-cor- 
puscle.^ 

Spirillum recurrens (Obermeier) was 
the first micro-organism seen in the 
blood. We find these organisms dur- 
ing an attack of recurrent fever. They 
disappear shortly before the decline of 
the fever. By careful examination they 
can always be demonstrated, although 
sometimes only a few of them are found. 
In a fresh drop of blood they appear 
(Hartnack 8, Zeiss F) as extremely fine 
threads, about five times as long as the 
diameter of a red corpuscle, with extremely active spiral, serpentine mo- 
tion. They occur either singly or several close together, sometimes 
lying together Hke a group of rats' tails. I have very often first seen 
them near white blood-corpuscles. The white or red corpuscle against 
which it lies is usually set slightly in mo- 
tion by the microbe, and hence we find it 
there best. Moreover, there often occurs 
in the blood slight leukocytosis ; also, we 
sometimes meet with shining granules (ele- 
mentary granules ? spores ?). As to stain- 
ing — which, after a little practice, is not 
necessary — see below. 

Tubercle bacillus exists in the blood as 
evidence of miliary tuberculosis. But in 
this disease we may lack this proof With 
the exception of one case observed by v. 
Jaksch it always occurs quite isolated. A 
special treatment is required for obtaining 
this microbe. We arrange a thin layer of blood upon the glass cover 
just as we do a preparation of sputum.^ 

Typhus abdominalis [typhoid fever] bacilli have in several cases 
been found in the blood, taken from one of the roseola spots and 
from veins, as short (one-third the diameter of the red corpuscle), 
thick clubs, rounded at the end.'* (For staining, see below). 



Fig. 90. — Anthrax bacilli in the 
arterial human blood (fuchsin-stain- 
ing ; Zeiss's homogeneous immersion 
lens yi^, eye-piece 4, camera lucida, 
magnified about 1000 diameters). 
The white line in the middle of the 
bacilli indicates only reflections. 
Prepared by Dr. Freimuth in Danzig. 







o 



o 



Fig. 91. — Spirillum recurrens in 
the blood (after v. Jaksch). 



1 Regarding staining, see below. 



'^ See Examination of the Stools. 



2 See Sputum, pp. iS9ff' 



EXAMINATION OF THE CIRCULATORY APPARATUS. 247 

[Serum Reaction in Typhoid Fever. — The Widal method of serum 
diagnosis of typhoid fever has been widely studied, and the more it has 
been investigated the more favorable have been the results. As modi- 
fied by Johnson, results have been obtained in 95 per cent, of cases. 
Others have not had so high a percentage of positive results. John- 
son's method is as follows : A drop of typhoid blood is received upon 
a bit of sterilized paper. This dried blood can be kept at ordinary 
temperature for a number of days without affecting the subsequent 
reaction. It is refluidized by a drop of sterile water. This is mixed 
with a drop of actively motile typhoid culture. The motion quickly 
stops, and the bacilli run together, forming loose coils or clumps. The 
time required for this varies from a few moments to several hours — some- 
times as many as twenty-four. Incomplete reaction is obtained as early 
as the second day of the disease, but complete reaction is seldom later 
than the fifth day. It may take place weeks or months after convales- 
cence, and hence it has been suggested that the Widal reaction is a 
defensive action — that is, that it is the beginning of an immunity. — 
Translator^ 

The bacilli of glanders are, in general, a little longer than the pre- 
ceding, but considerably slimmer. They have likewise been found a 
number of times in the blood of this disease. It is necessary to stain 
them,^ 

Mode of Procedure. — The greatest care and cleanliness is neces- 
sary in arranging a preparation of blood for microscopic examination 
for micro-organisms, although the minutiae of disinfection and steriliza- 
tion, as in preparing for culture, are not required. In malignant 
pustule and febris recurrens staining can be dispensed with. When it 
is necessary to stain a preparation, it is prepared by drying a small 
drop of blood which has been spread out and made as thin as possible 
by pressing two covers together. Then they are separated, allowed to 
dry in the air, and afterward passed two or three times through the flame 
of a spirit-lamp or a Bunsen's burner. If, now, we wish to examine for 
tubercle bacilli, a special treatment is necessary, as has already been 
described under Sputum, page 160. For other micro-organisms we 
stain with basic anilin colors (vesuvin, fuchsin, particularly methylene- 
blue, etc.), and then carefully rinse and examine in water, or, after 
drying, in Canada balsam. The staining is much more beautiful if we 
first briefly dip them in gentian-violet-anilin water,^ and then stain them 
a few minutes in Gram's iodin-iodid-of-potassium solution (iodin i part, 
iodid of potassium 2 parts, aq. destil. 300 parts), then in absolute 
alcohol. 



Malaria Parasites. — It is necessary to give a special description 
of the method of examination for malaria parasites — hcEinatobium 
malaricB, wrongly called plasmodium malariae. 

In 1880, Laveran described crescent-shaped bodies in red blood- 
cells which he found in Algiers in almost all forms of malaria, more 
frequently in severe ones. In the eighties, Marchiafava and Celli, Golgi, 
Celli, and Guarnieri studied this phenomenon in Italy. To-day it is 

^ See below. 2 gge above, under Sputum, 



248 SPECIAL DIAGNOSIS. 

established as a fact that in the blood of malaria patients, sometimes in, 
or more rarely upon, the red blood-corpuscles, again swimming free in 
the blood, there appears a parasite, of exceeding variety of form, which 
is never found in the blood of any other patients, and which finally dis- 
appears after the patient has taken sufficiently large doses of quinin. 
The parasite is found at the time of the fever, or its appearance in the 
blood precedes the fever. In slighter forms of malaria (febris quotidiana, 
tertiana, quartana) there seems to be no possible doubt that a new 
generation of the parasite in the blood corresponds with an attack of 
fever. The parasites of the severe forms of malaria, existing only in 
warmer countries, and those of the febris intermittens, which have 
alone to be considered in Germany [England and the United States], 
do not seem to be entirely identical. 

Method of Procedure. — A drop of blood is taken from the cleansed 
finger-tip or the lobe of the ear in the manner already described ; the 
cover-glass is strongly pressed upon it ; the preparation is protected 
from evaporation by surrounding it with wax. It is strongly to be 
recommended, after the method of Celli and Guarnieri, to mix the fresh 
drop of blood during its exit on the finger-tip with methylene-blue 
serum. ^ In the course of a half to one hour the leukocytes and the 
malaria parasites are stained, the latter very distinctly. Dry prepara- 
tions must be spread very thinly, are not to be passed through the 
flame, but are air-dried, fixed with absolute alcohol, in which they 
must remain about ten minutes, and dried again in the air. It is 
best then to employ a solution of eosin-methylene-blue (Plehn) : equal 
parts of concentrated watery solution of methylene-blue ; water ; 60 
per cent, alcoholic solution of eosin. Staining is continued from one 
to twenty-four hours, rinsed in water, etc. The solution must be 
filtered before using. It stains most intensely when two to eight days 
old, after which period its staining is less intense. Mannaberg ^ has 
lately recommended as the best a method proposed by Malachowski. 
The fluid consists of the following : 

Concentrated watery solution of methylene-blue, 24 ; 
5 per cent, solution of borax, 16; 

Water, 40. 

After standing twenty-six hours it is to be filtered. Specimens are to 
be stained in this for twenty-four hours, and then washed off in water. 
(Sometimes a few granules of eosin are added to the fluid.) 

The parasites appear as pale lumps of protoplasm which generally, 
but not always, enables one to recognize a differentiation in their sub- 
stance : lying within darker parts of protoplasm there are circumscribed 
hghter (also paler-colored) parts (" endoplasma "), which give the impres- 
sion of vacuoles. These latter, in preparations stained after the method 
of Plehn, shine through the eosin color of the blood-corpuscle stroma 
so intensely that the darker " ectoplasma " appears like a ring (see 
Fig. 92, I and 2). The larger formations contain red-brown or brown- 
black, nearly round or rod-shaped pigment-granules. Sometimes the 

^ Concentrated solution of methylene-blue in sterile serous transudation-liquid. 
* Fortschr. der Medicin, 1893. 



EXAMINA TION OF THE CIRCULA TOR Y APPARA TUS. 



249 



parasite appears in the form of a glomerular frame in the interior of the 
blood-corpuscles (4) ; rarely, in temperate climates, to appear in the 
form of a crescent (8) ; rare also is the so-called star-flower form of the 
protoplasm (5). The bodies swimming freely in the plasma (7) are dim 




Fig. 92. — Malaria parasites (eosin-methylene-blue. 5 and 7, unstained preparations). 
I, 2, 3, 6, two ring-like, one ball-shaped, one branched, Plasmodium ; 4, glomeruli form ; 5, aster form, 
beginning segmentation ; 7, complete segmentation ; Laveran's crescent ; 8 and 9, show vacuoles (partly 
after Dolega, partly after Quincke; magnified about loooX)- 



disks of the size of a red blood-corpuscle or smaller. In the fresh 
preparation the smallest sometimes appear like whip-threads. 

The parasites, similar to the leukocytes, in the fresh preparations 
show ameboid changes in form, which are somewhat quickened by 
warmth. Their pigment-granules are sometimes in lively motion, 
partly currents in the protoplasm, partly molecular movements. 

Later investigations seem to confirm an opinion expressed by Golgi, 
that different forms of the plasmodium correspond to different types of 
intermittent fever. Likewise, it seems to be certain, as has been men- 
tioned above, that other, smaller, forms of the parasites correspond to 
the severer malarial fevers as they occur, for instance, in Rome during 
summer and autumn. 

In black-water fever there have lately been found formations which 
very much resemble 4:he malaria parasites. 

At the same time with the malaria parasites there is a moderate 
leukocytosis, comparatively many eosinophile cells, and probably also 
leukocytes which enclose plasmodia. But, besides that, there is a very 
remarkable alteration i7i the red blood-corpuscles, which may cause, and 
has already caused, them to be confounded with the parasites : individ- 
ual red corpuscles in their interior show enclosures which appear as 
colorless or very palely-colored circles or clubs, ellipses, etc. They 
may lie concentrically, and are without doubt to be taken for deepened, 
sometimes also for steep-walled, dells, by which dells the stroma of the re- 
spective blood-corpuscles is made thinner, partly also by the disappear- 
ance of its substance. These pseiido-vacuoles (Quincke ; " vacuoles," 
v. Jaksch) are distinguished from the malaria parasites by being sharper 
circumscribed and of course free from granules, and that they are not 
stained by methylene-blue and do not show any ameboid movement, 
but frequently another — /. e., as it were, a pulsating movement — prob- 
ably conditioned upon the ascending and descending of the blood- 
corpuscles in the liquid layer. They also change their form from the 
circular into the ellipse form, etc. 



250 SPECIAL DIAGNOSIS. 

This alteration of the red blood-corpuscles seems to be a simple 
analogue of poikilocytosis. It is observed not only in malaria blood, 
but also in that of measles, scarlet fever, typhoid fever, ephemera, Hke- 
wise in anemic patients, in carcinosis, scurvy, leukemia, and now and 
then in the healthy. 

Finally, we briefly refer to two animal parasites which are met with 
in the blood (compare Figs. 93, 94), though they do not belong to our 
climate : the filaria sanguinis hoininis, which causes hematochyluria 




Fig, 93. — Distoma haematobium with eggs (after Fig. 94. — Filaria sanguinis hominis 

V. Jaksch). (after v. Jaksch). 

(in British India and Brazil), generally only found in the blood at 
night-time, and distoma hceinatobium (Bilharz), which causes a kind of 
hematuria, chiefly occurring in Egypt.^ 

Chemical Examination of the Blood. 

We content ourselves with a few hints regarding this department, 
which in recent times has been much elaborated. 

The interesting investigations made by von Jaksch regarding the 
percentage of nitrogen and albumin in the blood, by Stintzing regarding 
the percentage of water, and, most important of all, that the percent- 
ages of albumin and water are always in an inverse proportion, are 
topics which lie outside of the domain of diagnosis. 

Recently, in certain diseases, the degree of alkalescence of freshly- 
drawn blood has been determined by various methods, and it has been 
found that in severe anemia, fever, and diabetes (v. Jaksch), in de- 
composition of red blood-corpuscles, the alkalescence is considerably 
diminished. These investigations are not to be valued very highly, 
because their results are impaired by great technical difficulties. Uric 
acid in unusual quantity has been found in the blood in gout. It is 
also easy to demonstrate the amount of bile-pigment and urobilin in 
the blood and the amount of hemoglobin in the serum if the quantity 
of blood is sufficient— at least 3 c.cm. (Tissier, v. Jaksch). 

The quickness with which blood coagulates after it has been with- 
drawn varies in different diseases. In health coagulation takes place 
in about nine minutes. It is slower than this where the nutrition is 
chronically disturbed (H. Vierordt). 

Puncture in the tip of the finger or some other place, however, 
does not generally furnish the requisite quantity of blood for these 
examinations. They require somewhat larger quantities, which till 

^ See under Urine. 



EXAMINATION OF THE CIRCULATORY APPARATUS. 25 I 

now have been obtained by means of a scarificator and cupping-glass 
or by venesection. A short time ago v. Ziemssen proposed a method 
for obtaining larger quantities of blood, which in consequence of its 
harmlessness and exactness may be substituted for the two last-named 
methods. With the necessary asepsis blood is taken from the median 
vein on the forearm after having stemmed the blood by light compres- 
sion on the upper arm. The blood is removed by a small aspirating 
syringe whose needle is thrust into the vein in a distal direction and 
pushed in parallel to the skin. In this way, at discretion, smaller or 
larger quantities of blood may be drawn, and the procedure may also 
be repeated at the same place. 



CHAPTER VI. 

EXAMINATION OF THE DIGESTIVE APPARATUS. 

MOUTH, PALATE, AND PHARYNGEAL CAVITY. 

The Mouth. — The inspection of these parts requires good illumina- 
tion, and for a portion of them, in many cases, a quick view. Bright 
daylight is better than artificial light. The mouth is to be opened widely, 
the tongue protruded, and not only put out, but, for inspecting its bor- 
ders, turned from side to side. (For examining it with reference to 
paralysis, see Nervous System.) In order to inspect the mucous mem- 
brane of the mouth, we turn out the upper and lower lips with the finger, 
the mouth being closed ; then, the mouth being opened, we carefully lift 
the mucous membrane of the cheeks from the back teeth with a mouth- 
spatula (made of ivory, hard rubber, horn, or metal [best of all, glass]). 
The gums are examined by opening the mouth as widely as possible and 
holding the tongue down carefully with a tongue-depressor (a teaspoon 
serves very well). The back of the mouth is best brought into view 
by having the patient say distinctly a (full elevation of the soft palate). 
Often the patient must be required to drink some water, or to clear the 
throat thoroughly by hawking before it is examined. If we meet with 
opposition, especially in children, it is sometimes necessary to hold the 
nose, and thus compel them to open the mouth. When a child cries, 
we are able to see very well. It is often useful to cause the sensation 
of strangling by putting the tongue-depressor far back, and thus we 
are able to see the tonsils better — of course, only for an instant. [One 
learns, by practice, to take a very perfect and complete view of the 
whole cavity of the mouth and pharynx in this instant of strangulation, 
and then can carry the mental picture long enough to note all its par- 
ticulars.] 

But we must guard against being too harsh or rough with children 
with dipJitheria^ or with any very sick patient. In diphtheria imme- 
diate death may follow an effort at examining the throat. With those 
who are unconscious it is necessary to cause gagging in order to 
inspect the posterior part of the mouth. In marked cases of this char- 
acter it is often impossible to obtain a view at all. 

Palpation is only rarely employed for examining the tongue, floor 
of the mouth (making counter-pressure from without), the tonsils, or 
the back part of the pharynx. We employ the index or this and the 
middle fingers, which have been carefully washed in the presence of 
the patient. 

The odor from the mouth is, in many cases, important. A foul odor 
—foetor ex ore — results from imperfect cleansing of the teeth, caries of 
the teeth, or dyspepsia. From this odor we distinguish the stale, and 

252 



EXAMINATION OF THE DIGESTIVE APPARATUS. 253 

at the same time foul, fetor from considerable old deposit in the mouth 
of patients who are very ill. If the sense of smell is acute, one can also 
distinguish a slight cadaveric odor upon patients who are very sick, 
even if the mouth is quite clean, and sometimes it precedes death. 

Of much more diagnostic value are the different odors which we 
meet with in poisoning from prussic acid, phosphorus, alcohol, and 
chloroform ; but the former two, even in recent cases, may possibly 
be wanting. Lastly, we mention the odor of fruit, wrongly called 
''acetone" odor, very like fresh apples, which sometimes occurs with 
the so-called chlorid-of-iron reaction of the urine ^ in diabetes, espe- 
cially before or during the onset of diabetic coma, or during its course, 
as well as in other conditions.^ 

The I/ipS. — With regard to their color (pale, cyanosed, etc.) we 
can refer to what has already been said when speaking of the mucous 
membrane. Dryness of the lips is seen in connection with dryness of 
the tongue.^ There is marked dryness in severe febrile diseases, with 
a dirty-looking crust adherent to the mucous membrane, which easily 
bleeds when this is removed (fuliginous deposit). Small cracks 
(rhagades, crevices) are, in themselves, without significance. On the 
contrary, in children rhagades are an important, generally a positive, 
sign of hereditary syphilis. 

In persons affected with hereditary syphilis, in rare cases, one sees, 
besides, peculiar deep wrinkles in a radial position round the mouth. 
They particularly run toward the corners of the mouth in the manner 
of 2, pes anseriniLS, hut occasionally they also go as from the chin to the 
lower lip. They might be taken for linear scars were not their origin 
in corresponding long and deep rhagades excluded. I have seen them 
in children a few months old, as well as in adults, but exclusively in 
hereditary syphilis. Their origin is not at all clear. 

The Teeth and Gums. — We must take their condition into con- 
sideration together, and, besides, as to whether the teeth are sound. 
In small children we notice whether the first teeth have all come ; 
in the later years of childhood, the change to the permanent set. 

There is often marked cai^ies of the teeth in diabetes mellitus, thouo-h 
it IS very common without this disease. A circular excavation of the 
lower edge of the upper middle incisor teeth of the second dentition 
[Hutchinson's teeth] sometimes occurs, although it is a very uncertain 
sign of congenital syphilis, with catarrh of the middle ear and parenchym- 
atous keratitis, the whole forming the so-called Hutchinson's triad — 
a group of symptoms which very seldom present themselves, whose 
significance in the diagnosis of hereditary syphilis does not seem to us 
so infallible as was formerly supposed. Imperfect and diseased teeth, 
interfering with mastication, are often the chief cause of dyspepsia. 

Loosening of tlie teeth, and the gums discolored bluish-red, receding 
from the teeth, easily bleeding, and even inflamed, are important symp- 
toms of scorbutus. Loose teeth, with moderate swelling, is a sign of 
chronic poisoning with mercury. 

A grayish deposit upon the teeth, and especially a gray line along 
the dental border of the gums, are of importance for the diagnosis of 

^ See chapter on Urine. 2 ggg chapter on Urine. 

^ See l:)elow, p. 254 f. 



254 SPECIAL DIAGNOSIS. 

chronic lead-poisoning. In poisoning by copper we have sometimes 
the same condition, only the color is greener. 

The emption of iJie fii'st teeth is a source of much disturbance in the 
mouths of the little patients. Occasionally it gives rise to serious dis- 
turbances — diarrhea in rare cases, epileptiform attacks (eclampsia of 
children, infantile convulsions, spasms of dentition), also spasm of the 
glottis. Also, second dentition and the eruption of the wisdom teeth 
are not infrequently accompanied with limited or general oral dis- 
turbances, sometimes likewise the cause of abscess. 

To the red border upon the gum, observed by Fredericq-Thompson, 
which in young subjects is said to be a very suspicious sign of tuber- 
culosis, we have given careful attention for a long time, and conclude 
that it has no significance. 

The Tongue. — For paralysis and neurotic atrophy of the tongue, 
see under The Nervous System. 

Enlargement of the tongue, if slight, is only to be determined from 
the indentations on its borders by the lower teeth. This occurs with 
the various forms of stomatitis. Marked enlargement of the tongue 
may be caused by parenchymatous glossitis, tumors, and also by 
severe angina, which produce venous engorgement of the tongue. 
Moreover, there are very great individual variations in the size of the 
tongue. 

Circumscribed swelling and hardness, or the latter alone, are the 
first evidences of carcinomatous or syphilitic formations of the tongue. 
It is extremely difficult to make the very important differential diag- 
nosis between these new growths, and usually it can only be made ex 
juvantibus, or by microscopically examining a small piece, which can 
easily be removed from it.^ 

Wounds and the resulting scars, sometimes accompanied with 
swelling, are frequent appearances after epileptic attacks and result 
from biting the tongue.^ We never see the tongue bitten in hystero- 
epilepsy. 

If the tongue trembles when it is protruded, or if it does so when 
within the mouth, it is a valuable sign of chronic alcoholism. This is 
also the case in severe fevers, and especially early in typhus abdomi- 
nalis [typhoid fever]. In these cases, when there is marked hebetude, 
the patient often will not draw in his tongue after protruding it unless 
he is directed to do so. 

The color of the tongue is affected by that of the blood : cyanosis 
afifords the most marked instance of this. It is quite common to find 
local redness with febrile conditions. It often goes side by side with 
the febrile redness of the cheeks. Mulberry tongue is one in which 
there is a decided redness with swelling of the papillae, and is an 
important sign of scarlet fever, which in individual cases may develop 
before the cutaneous eruption. Very often the coating of the tongue 
conceals the color of the mucous membrane. 

When the saliva is glutinous or diminished it causes the tongue to 
be sticky or dry. In connection with dryness of the throat febrile 
diseases cause thirst. When the fever is very high the dryness is often 
increased by the patient keeping his mouth constantly open. Then the 

1 Regarding this, see works upon Surgery. ^ ggg under Scars. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 255 

surface of the tongue, if free from coating, first becomes horny, then 
quickly very smooth, and soon rough and cracked. 

Coating of the tongue as a thin white layer is often constant in 
health. When a tongue which previously was clean becomes coated, 
especially if thickly coated, it indicates dyspepsia. There is very marked 
coating of the tongue in severe acute and chronic diseases of the stom- 
ach and with the dyspepsia of fever. With the latter it is often discol- 
ored brownish-red from small hemorrhages of the mucous membrane. 
When there is great dryness of the tongue it becomes covered with 
crust, which adheres so closely that when removed the mucous mem- 
brane bleeds. Articles of diet may cause temporary coating or they 
may color the coating that is already there (milk, cocoa, coffee, etc.). 

A thick white — often also a discolored — coating on the tongue may 
depend upon the development of thrush (oidium albicans). In very 
pronounced cases it forms separate small tufts about the size of a 
millet-seed, which spread out and coalesce. It is cheesy and tolerably 
adherent. It may cover the surface of the tongue, the soft and hard 
palate, the mucous membrane of the cheeks ; it may even extend down 
into the esophagus ; occasionally we see the whole surface of the mouth 
and throat covered with it. [The translator has seen a few cases where 
it seemed to have spread the whole extent of the alimentary tract, 
appearing about the anus.] Small children have it quite often, adults 
only in cases of severe illness when the care of the mouth is neglected, 
especially in fevers, diabetes, tuberculosis, etc. Whenever there is a 
thick coating in the mouth we must think of this growth, because its 
early recognition is very important. The diagnosis is promptly made 
by the aid of the microscope.^ 

For scars from biting of the tongue during an attack of epilepsy, see 
above, under Wounds. Dense, often depressed, scars upon the surface 
of the tongue indicate healed syphilitic ulcers. 

In tertiary syphilis there is not infrequently a peculiar smoothness 
of the mucous membrane of the back of the tongue at its root, which 
is to be explained by an atrophy of the mucous membrane, and particu- 
larly of the follicles of the tongue. This alteration may be perceived 
by palpation and by examination with a mirror. 

Mucous Membrane of the Mouth. — When there is a suspicion 
oi syphilis the mucous membrane of the mouth must be examined with 
the greatest care (scars, ulcers [mucous patches]) ; also when there is 
a possibility of poisoning with strong mineral acids or alkalies, corro- 
sive sublimate, carbolic acid (superficial gray color, and under it marked 
injection of the mucous membrane, raw patches). It may also be the 
seat of catarrhal nlcers as well as of the development of thrush.^ Can- 
€rum oris (noma) usually begins with a circumscribed bluish-black dis- 
coloration of the mucous membrane of the cheek or an ulcer with this 
condition around it, and with a thick, inflammatory infiltration of the 
cheek. It is a kind of spontaneous gangrene with a decided reactive 
inflammation in poor, wasting children. It is a rare disease. 

We examine the floor of the mouth by palpation from within and 
without. It may be the seat of very dangerous inflammation (angina 
Ludwigii). 

^ See next page, 2 3gg below, also above. 



256 



SPECIAL DIAGNOSIS. 



Salivary Glands and Saliva. — Of the former we notice only the 
parotid gland. When it is inflamed there are pain and swelling, and if 
it proceeds to the formation of an abscess, there are also redness and 
fluctuation above the angle of the jaw. 

The saliva is increased (salivation, ptyalism) by all kinds of irritation 
that affect the mucous membrane of the mouth — physiologically by 
eating, pathologically by all inflammatory conditions of the mouth 
(ulcers, inflammation of the gums in connection with affections of the 
teeth, dental abscess, etc. ; corrosive action of acids, alkahes in the 
mouth and throat) ; also, in chronic mercurial poisoning : and, lastly, 
sometimes in disease of the medulla oblongata.^ The saliva is diinin- 
islicd in febrile diseases, in diabetes, in severe diarrhea (cholera). Thus 
far, the chemical examination of the saliva has been of no diagnostic 
value. It is of interest that in nephritis it may contain urea, and also 
that thus far there has never been discovered in it any coloring matter 
from the bile, nor any sugar. Many substances, like iodid of potassium, 
after they have entered the stomach appear remarkably quickly in the 
saliva. 

Microscopic iExamination of the Contents of the Mouth. — 
Normally, we find flat epithelial cells from the upper layer of the 




Fig. 95. — Leptothrix buccalis, from the sputum of a phthisical patient. Fresh specimen treated 
with lactic acid and Lugol's solution. Magnified about 300X. 



mucous membrane of the mouth, separate white blood-corpuscles, and 
likewise micrococci, bacilli, and spirocheta in great abundance. 
Among these are very long threads of variable thickness, often 
arranged parallel, and resembling a tuft of hair. They are especially 
found in the material adhering to the teeth. They take a brilliant 
violet color if the preparation is a little acidulated with 5 per cent, 
solution of lactic acid and a drop of Lugol's solution is added. These 

^ See Bulbar Paralysis. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 257 

formations have formerly been described as a single fungus, leptotJirix 
biiccalis. It has, however, been asserted that different bacilli in the 
secretions of the mouth are peculiar in that they grow out in long 
threads and give the iodin reaction. It is certainly a striking fact that 
some short portions become stained by iodin — some just as much and 
some a little lighter than the leptothrix. Nevertheless, and although 
certain results of culture furnish ground for the opinion, we do not 
think the point has yet been proved. We rather think there is reason 
to believe in the oneness of character of the so-called leptothrix 
threads which occur in the mouth (and in the tonsils and sputum).^ 

Of considerable importance is the appearance of pathogenic micro- 
organisms in the buccal secretion of healthy persons. From it there 
have been produced by culture the bacterium of rabbit septicemia, the 
sarcina-like micrococcus tetragenus (it has been alleged also), actinom- 
yces (?), a diplococcus similar to Frankel's, the bacillus of diphtheria, 
and lastly strepto- and staphylococci. 

Furthermore, some bacteria of the mouth show a striking resem- 
blance in the culture to certain pathogenic fungi, without being identical 
Avith them, as, for instance, a bacterium which is similar to the comma 
bacillus and one similar to that of the recurrens spirochaeta. 

Again, there are found a great number of non-pathogenic bacilli and 
cocci. 

In general, the bacteria of the mouth are increased in all forms of 
dyspepsia ; they are found in very great quantities in persons suffering 
from any severe disease, and in all forms of stomatitis. 

Two diagnostic points have yet to be emphasized : 

It is easy to recognize the thrusJi-fiingus under the microscope by 
the characteristic, tolerably broad, light fungus-threads (they are more 
than half as broad as a white blood-corpuscle) and by their roundish- 
oval, clear granules. 

Suppurations in the mouth proceeding from the inferior maxilla are, 
-in rare cases, caused by actinomyces. Whenever there is a discharge 
of pus into the mouth we must remember the characteristic granules.^ 

The soft palate, the uvula, palatal arches, and tonsils are the seat of 
diseases of the most different kinds. These parts, also, are exposed to 
the greatest variety of injuries, particularly to infections, since not only 
the nourishment which is brought to the body passes along them., but 
also the respiratory current of air, and since they probably also partici- 
pate in infections which are taken up from the mouth-cavity, principally 
by kissing. In addition, there is a local disposition to the absorption 
of infectious germs, which disposition is without doubt peculiar to the 
tissue of the tonsils. Thus all possible kinds of pathogenic cocci — 
diphtheria baciUi, syphilis-poison, tubercle bacilli, leptothrix, actino- 
myces — find lodgement in the palate or its immediate surroundings. 
There are also chemical injuries — i. e. corrosions in poisoning with 
strong acids and alkalies — and mechanical ones by fish-bones, bone- 
sphnters, puncturing the tissues. 

Of some infectious diseases not mentioned here it is still unproved, 
but probable from clinical reasons, that they obtain their entrance 
through the tonsils. In scarlet fever this is an extremely probable 

^ See pp. 150 and 263. 2 ggg p_ j^g; Microscopic Examination, see p. 150. 

17 



258 



SPECIAL DIAGNOSIS. 



supposition ; but it occurs also in measles, in some cases of articular 
rheumatism and typhoid fever, in certain infectious forms of nephritis. 

In a manifold way the tonsils, moreover, are the seat of origin of a 
septico-pyemic general disease ; that is, either by the immediate pri- 
mary absorption of pyogenic material (tonsillar abscess as a cause of 
septicemia) or by secondary infection in the tonsillar tissue which has 
been prepared by some other primary disease. One must think of the 
secondary invasion of pus-cocci in bacillar and in scarlet-fever diph- 
theria. The form and color of the individual parts of the palate must 
be carefully observed. An exact knowledge of the normal appearances 
is of course indispensable for a correct judgment of pathological con- 
ditions. 

As regards the general rules for the diagnosis of these different 
morbid states, the directions which we have given on page 252 
must be carefully observed. It is particularly desirable to examine 
difficult cases, which are notably frequent, by dayhght or in an artificial 
white light which most nearly resembles daylight. The form and color 
of every part of the palate must be observed. An exact knowledge of 
the normal conditions, as has been said, is of course indispensable for a 
correct judgment. 

Special diagnosis cannot of course be here entered into exhaustively. 
We take only the most essential points : 

Chronically hypertropJiied tonsils are to be distinguished from freshly 
inflamed organs by their normal color and insensibility. Wide and 
deep empty lacunae point to frequent attacks of angina [tonsillitis]. 

Secondary syphilis produces on palate and tonsils condyloma-like 
plaques — i. e, broad, flat, sharply defined, whitish patches, or simply 
reddened spots which are striking by their sharp demarcation and a 
never-failing, although small, elevation. Finally, there are also seen 
flat or deeper, always sharp-edged, ulcers with gray-colored edges. 
Tertiary syphilis produces more solid infiltrations, with ulcers of quite 
different depth, covered with yellow purulent matter. From this cause 
also there may be great defects of the palate. Syphilitic scars are 
recognized by their sharply distinct white lines on the tonsils, often by 
simultaneous deep retractions. A favorite seat of these scars is the 
upper part oi the posterior palatal wall, which becomes visible only in 
pronouncing a. 

The acnte anginas form a group of cases of great variety. In the 
foreground of interest stands the question as to how clearly the forms 
associated with genuine exudations can be distinguished from one 
another and from the simple lacunar and necrotic anginas. The ques- 
tion which arises most frequently is regarding a differential diagnosis 
between bacillar diphtheria and lacunar angina [follicular tonsillitis]. 
Mistake is impossible in fully-developed diphtheria. The strongly ad- 
hesive, whitish exudation adheres to the tonsils as a solid membrane, 
spreads in irregular form over the neighboring tissues on to the soft 
palate and farther into the buccal cavity. Also, in the beginning of 
diphtheria the distinction can often be made with certainty, because 
even the small, closely adherent exudations, irregular in shape, are dis- 
tinguished from the plugs of lacunar angina [follicular tonsillitis], the 
one variety being closely adherent and irregular in shape, while the other 



EXAMINATION OF THE DIGESTIVE APPARATUS. 259 

can be readily detached from their lacunae, and are round, slightly pro- 
truding, yellow masses. But sometimes diphtheria commences likewise 
in the form of small, roundish, plug-like formations scattered on the 
tonsils. If viewed closely, they often show suspicious peculiarities : 
they are strikingly whitish ; they do not rest in the lacunae, but on 
prominent spots of the tonsils ; further, they occasionally resemble 
nail-cultures — i. e. they very early show a deUcate membranous super- 
ficial surface around the plug, resting in its lacuna. But occasionally 
these signs fail : the angina certainly seems to be lacunar [follicular 
tonsillitis], but the bacteriological examination and the further course 
proves it to be diphtheria. I have directed my attention to these things 
for years, and am obliged to strongly take issue against Sahli that 
these happenings are not too rare. 

Lacunar angina \_follicular tonsillitis], which occurs during epidemics 
of diphtheria, or, worse still, in families, houses, and schools, ought 
immediately to be examined bacteriologically and isolated. 

More difficult still is the early distinction of diphtheria from simple 
necrotic angina, which sometimes occurs as a primary disease, and is 
then usually unilateral, or as a primary lacunar angina. The exuda- 
tions of these forms adhere less closely than the diphtheritic, and they 
do not extend beyond the tonsils ; but these are of course uncertain 
signs. Here, too, it is well to examine bacteriologically. 

Finally, there is the differential diagnosis of diphtheria from the 
other forms which are associated with exudations. 

Scarlet fever is often distinguished by a gray, dirty, or very delicate 
membrane ; in other cases it strikingly resembles bacillary diphtheria, 
with which etiologically it has nothing to do. The diagnosis is clear if 
the complex of symptoms of scarlet fever is distinctly pronounced. It 
must be observed, however, that in bacillary diphtheria complicating 
scarlet-like exanthemata may be caused by sepsis — that, vice versa, in 
scarlet fever the exanthema may be rudimental or even entirely absent. 
An extension to the larynx always points to bacillary diphtheria. 

There are, besides, some peculiar diphtheroid anginas caused by 
strepto- and staphylococci which have nothing to do with scarlet fever. 
These generally have an entirely different appearance from diphtheria : 
the coating is gray or yellowish, delicate and soft, frequently, however, 
as sharply circumscribed, as decidedly adherent, as the genuine diph- 
theritic membrane. They may also extend beyond the tonsils. These 
affections are certainly transmissible, but they remain confined to the 
palate and the prognosis is favorable. They have, therefore, to be 
separated from diphtheria, not only etiologically, but also for other 
reasons. But it is principally these affections, besides scarlatinous diph- 
theria, which have led many authors to speak of a genuine diphtheria 
without bacilli, and to doubt the etiological significance of Loffier's 
bacillus. 

We recognize an abscess of the tonsil by its [usually] being on one 
side only, with swelling of the anterior arch, by the fluctuation (which 
is felt with the finger). 

Long-continued ulcers of the tonsils and soft palate are generally 
syphilitic, more rarely tubercular. In the latter case there are often, 
besides, larger ulcers, or also, without them, a broad, reticulated, puru- 



26o 



SPECIAL DIAGNOSIS. 



lent discoloration of the mucous membrane, which reminds one of 
slightly-inflamed pleura covered with a fine fibrinous exudate. For 
paralysis of the throat — see Nervous System. 

/;/ tJic pharynx we look for possible chronic or acute inflammation 
and ulcers ; in cJdldrcn who, for some unknown reason, swallow badly 
and have distress in breathing, for possible sweUing of the posterior 
pharyngeal wall {I'ctropJiaryngcal abscess, the fluctuation in which may 
be detected by palpation). 

We must always examine the lymphatic glands in the neck in con- 
nection with the examination of the throat. In all acute inflammations 
of the latter they swell, most markedly in diphtheria, also in chronic 
inflammations, especially in syphilis. 

From what has been said above the inference will readily be drawn 
that after much practice and large experience, especially by training 
the eye to make sharp distinctions and by becoming familar with the 
normal and the pathological pictures, one may be able by simple in- 
spection to make a very close approximation to an accurate diagnosis 
of the affections of the palate ; but, nevertheless, it is frequently neces- 
sary to employ the bacteriological examination, especially when it is a 
question as to the existence of diphtheria or tuberculosis. 



Microscopical and Bacteriological Examination of the Palate and 

Pharynx. 

When tuberculosis of the palate and pharynx is suspected, by 
means of a flexible spatula, such as is used in microscopy, we scrape 
some particles from the bottom of the ulcers, and make cover-glass 
preparations, which are to be examined for tubercle bacilli like sputum- 
preparations. As these patients always suffer also from tuberculosis 
of the lungs (or larynx), it is necessary to be careful not to get any 
sputum, which adheres accidentally to the mucous membrane, upon the 
spatula. For this reason it is desirable to have the patient gargle 
before commencing the manipulations. 

Bacteriological Diagnosis of Genuine Diphtheria. — In every case 
of necrotic angina or of angina with exudation which is in the least 
doubtful one must examine for diphtheria bacilli. The conscientious 
physician, who regards the danger to which children are exposed, will 
also subject lacunar anginas to this examination. The reason for this 
is clear from what has been said above. At the present time we are 
positive that genuine diphtheria is always and only produced by Lof- 
fler's diphtheria bacillus ; the cause of simple necrotic and simple lacunar 
angina we do not yet know. The cause of scarlet-fever diphtheria is 
either the yet unknown, peculiar scarlet-fever poison, or a chain coccus, 
which is never absent in scarlet-fever diphtheria, and may also extend 
from this into the surrounding tissues, the glands, and the circulation. 
At any rate, the genuine Lofller's bacillus is also found in convalescence 
from diphtheria, and it has even been found in isolated cases in healthy 
persons (Loffler, Babes, v. Hoffmann) ; but that will scarcely interfere 
with the differential diagnosis in a case of doubtful acute angina [follic- 
ular tonsillitis]. On the other hand, it is of greater significance that in 
microscopical examinations the bacillus may be easily confounded with 



EXAMINATION OF THE DIGESTIVE APPARATUS. 



261 



other similar ones : in the diphtheria membrane it neither has always a 
characteristic appearance nor has it a specific coloration peculiar to itself. 
Therefore, t/ie exact proof of tJie diphtheria bacillus can generally only be 
furnished by cidture. If the specimen is spread on an agar plate, a reli- 
able result in a positive case can be obtained in twenty-four hours. It 
rarely requires more time for the development of characteristic colonies, 
and also there are rarely so many different bacteria that a second plate 
is needed. Likewise, it is seldom necessary to make a bouillon culture, 
as the bacilli develop very typically on the plate.^ 

The vaccinating experiment can almost always be dispensed with 
for the purposes of diagnosis. 

However, the simple microscopical exanmiation of a piece of mem- 
brane, according to our experience, sometimes gives an immediate 
positive result, and it should never be omitted in a doubtful case ; for 
if in the pieces of membrane there are found oblong bacilli in heaps or 
only in nests, or even if they are found only here and there quite dis- 
tinctly, without admixture of cocci, etc., we have always to do with 
diphtheria. If, however, only isolated specimens of Loffler's bacillus 
are found mixed with other baciUi and cocci, no conclusion can be 
drawn from the preparation. Culture alone can decide.^ Our exami- 
nations have shown that just in the beginning of the disease the 
microscopical preparation sometimes does not permit a reliable conclu- 
sion ; and this is certainly often annoying, for an early diagnosis is 



W-1, 



'1 'I 



c^ 









c\- 















\N_- 






^ 












vmf' , / 



1/ 



Fig. 96. — Diphtheria bacilH, froia mem- FiG. 97. — Diphtheria baciUi with mixed 

branes taken during hfe. Staining with Loffler's cocci. Preparations from membrane taken 
potassium-methylene-blue, washed with water. during hfe. Staining with Loffler's potassium- 

methylene-blue, washed with water. 



important in order that specific treatment may be instituted as early as 
possible. 

The loss of time by the plate method is, as was mentioned above, 
at least twenty-four hours. In a doubtful case, therefore, it is best to 
use the specific treatment before the final decision is reached. 



See Appendix. 



See Appendix. 



262 



SPECIAL DIAGNOSIS. 



Mode of Procedure.- 



T 



^^P 



'\ 



•^\ 



^^ 









A small piece of the membrane or of a plug 
from a lacunar tonsil is to be removed 
with sterilized pincers and teased on the 
cover-glass with a sterile microscope- 
\^_^ needle ; then it is to be pressed carefully 
'' ' (not too much) between this and a 
second cover-glass. These are next to 
be separated one from the other, dried, 
and stained with Loffler's potassium- 
methylene-blue solution (30 c.c. of 
alcoholic solution of methylene-blue ; 
100 c.c. of 0.0 1 per cent, liquor potassii) ; 
rinsed in water. 

Mode of Procedure for a Bac- 
teriological Diagnosis of Diph- 
theria. — An extended series of parallel 
experiments has shown us that for a 
quick and reliable demonstration of the presence of diphtheria baciUi 
it is by far the most advantageous to remove a particle of the exuda- 
tion or of a plug. We have therefore abandoned the different methods 



■^^. 






^^d 



.y 



Fig. 98.— Diphtheria bacilli (Lof- 
fler) from bouillon culture. Stained 
with Lofifler's methylene-blue — Zeiss 
homog. immers. r^^, oc. 4. 




Fig. 99. — Spoon-forceps (natural size). 



of wiping or scraping off of the exudation with pledgets of wadding, 
sponges, loops of platinum, or spatules, and always use a well-sterilized 
long, sharp, spoon-pincers, with which it is easy, with a little practice, 
during the inspection of the pharynx to obtain a small particle of exu- 
dation and even of a deep-seated plug. If it is desired both to use the 
microscope and to make a culture, it is best to remove two particles — 
the first from the pincers with a sterile needle, and to leave the second 
in the pincers till a culture is made. The pincers are sterihzed every 
time immediately after use by boiling in a solution of soda, and pre- 
served in a sterilized test-tube closed with a pledget of wadding. After 
use the pincers are immediately put into the test-tube again, together 
with the particles which have been removed, and left in the tube until 
the culture is made. The pincers may be carried in the pocket 
enclosed in a test-tube of strong glass. 

The particles which are destined for the microscope are placed with 
sterile needles between two carefully cleaned, strong cover-glasses, 
which are to be pressed firmly together, then separated, dried, and 
stained with Loffler's potassium-methylene-blue, and rinsed in water. 
The particle destined for culture it is best to spread in three lines upon 
congealed Deicke-agar plates. 

In a case of suspicious croupous laryngitis without disease of the 
pharynx, the pharynx, if possible, is to be wiped energetically down to 
the epiglottis with a sterile pledget of wadding to be used for the cul- 



EXAMINATION OF THE DIGESTIVE APPARATUS. 263 

ture. The microscopical preparation from such a case is generally 
without diagnostic result. In examining a case of convalescence from 
diphtheria for possible still present bacilli, the tonsils are wiped and the 
culture made in the way just described. A like method is pursued if 
there is an exceptionally deep-seated, suspicious tonsillar plug. 

The culture of diphtheria bacilli and its results are discussed in the 
Appendix. 

A luxuriant growth of leptotJirix in the pliarynx i^pharyngoinycosis 
leptothricia ; algosis faiLcuim IcptotJmcid) may occur in the form of 
long-existing, quite or almost quite unirritating lacunar plugs, which, 
on inspection of the tonsils, either look like common plugs or 
appear flatly imbedded in the mucosa, and are then scarcely per- 
ceptible. 

In individual cases this affection may extend from the tonsils par- 
ticularly to the follicular glands at the root of the tongue, or even still 
farther into the trachea itself They manifest themselves as a number 
of distinct, elevated, yellowish-white specks. The nature of these 
deposits is easily recognized under the microscope, especially after the 
addition of iodin ^ (compare further regarding leptothrix buccalis, page 
257). 

EXAMINATION OF THE ESOPHAGUS. 

Preliminary Anatomical Remarks. — The esophagus begins at 
the level of the cricoid cartilage of the larynx ( = the lower border of 
the sixth cervical vertebra), and extends to the stomach at about the 
height of the base of the xiphoid process. At first it lies immediately in 
front of the vertebrae ; then it comes a little forward, and at about the 
seventh dorsal vertebra it bends a little to the right, then again to the 
left, to reach the esophageal opening in the diaphragm. In adults the 
esophagus is about 25 cm. long. When we employ an esophageal 
sound ^ we estimate the distance from the incisor teeth to the stomach 
at about 17 cm. in the newly-born, while with adults it is about 40 cm. 
In the latter the distance from the incisor teeth to the bifurcation of the 
trachea is about 22 cm. The esophagus does not have the same 
diameter throughout : its narrowest points are at the commencement 
and where it perforates the diaphragm. The neighboring organs with 
which it has important relations in different diseases are — the trachea 
for the upper 7 to 8 cm. of the esophagus, the bronchial glands, the 
pleura, the pericardium, the aorta from the bifurcation of the trachea 
downward ; lastly, the recurrent nerve from the bifurcation upward. 
It is only in the neck that the esophagus can be felt from without. 
Below the neck we cannot employ the usual methods of examina- 
tion. 

CJiaracteristic distress almost always occurs with certain diseases 
of this organ — namely, with those conditions which result in stenosis 
(stricture) : there is more or less deeply-seated difficulty in swallow- 
ing ; the patient after taking food has a feeling of pressure, or even of 
pain, in the neck or the chest — a feeling that what has been taken 
cannot be passed dov/n. According to the place or degree of the 

^ See p. 257. 2 See next page. 



264 SPECIAL DIAGNOSIS. 

stenosis, the patient experiences difficulty only after taking large, 
slightly comminuted bites of food, or even after swallowing soup or 
fluids, either immediately after the former or only after many bites or 
swallows. Moreover, the food may be regurgitated, wholly or in part, 
some time after it has been taken. Then we distinguish it from vom- 
iting by the absence of odor, of acid reaction, and of muriatic acid. 
Pain in swallowing, without stenosis, occurs with inflammation of the 
mucous membrane of the esophagus or in its near neighborhood 
(mediastinum). 

Examination of the esophagus itself is almost confined to direct 
palpation from within by means of the sound, excepting that in the 
cervical portion we can employ inspection and palpation from without. 
Auscultation furnishes little aid ; the same is true of percussion. But 
it is very important in many cases to examine the neighborhood, par- 
ticularly the thorax. 

Only in exceptional cases do inspection a7id palpation of the cervical 
portion yield any result, because the great majority of diseases of the 
esophagus are located quite below the bifurcation of the trachea. We 
can feel a carcinoma of the cervical portion (likewise swelling of the 
glands of the neck) ; we can feel, and often also see, pulsating diver- 
ticula when they are full— that is, after the patient has eaten. Carci- 
noma of the lower end of the esophagus can be felt from the abdomen 
if the cardiac end of the stomach is encroached upon. Pain from 
pressure in the neck occurs in the conditions above named and in 
inflammations, as, for instance, after swallowing acids and alkalies. 

Direct Palpation ; Examination with the Sound. — For diag- 
nostic sounding of the esophagus we employ either a whalebone or a 
French or English (black, yellow, or red) hollow and fenestrated esopha- 
geal sound. We think the solid, so-called esophageal bougies can be 
dispensed with. The whalebone sound consists of a thin staff with an 
olive-shaped ivory knob screwed upon one end. We have knobs of 
different sizes in order to determine and measure the degree of the 
stenosis.^ Before using we are to make certain that the bulb is secure 
upon the staff, and also that the whalebone is perfectly smooth, so as 
not to catch anywhere or to cause injury. This sound furnishes the 
most positive information, and yet its use requires the greatest dexterity 
and caution. The cylindrical India-rubber sounds (especially the 
English esophageal sounds, which are the hardest) before using must 
be somewhat softened by dipping in warm water. Begin the examina- 
tion with a thoroughly softened rubber sound, and only resort to the 
whalebone later. 

Before introducing it we are to moisten the rubber sound its en- 
tire length, or the knob of the whalebone sound, with white of &^^, 
glycerin, or with olive oil (but not with water). The patient, with the 
chin somewhat elevated, sits upon a chair or the edge of the bed. The 
index and middle fingers of the left hand are introduced into the mouth, 
and with them we slowly feel as far as the root of the tongue. Then 
we seize the sound with the right hand, like a pen-holder, and slowly 
push it along the tongue under the two fingers. As soon as the point 
of the sound passes beyond the ends of the fingers we press its end 

^ See below. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 265 

somewhat downward with the tips of the fingers, and at the same time 
elevate the right hand, so that the sound may not strike against the 
back of the throat. The sound is then with gentle pressure pushed on, 
always holding it as if writing. The left hand is now withdrawn. 

Special precautionary measures, such as placing a cork between the 
teeth or anything to hold the jaw, are usually not necessary, since this 
operation is not performed upon unwiUing or unconscious patients (it 
is otherwise when sounding the stomach).^ Only with children are we 
sometimes obliged to use the cork. Many patients bear a skilfully- 
performed sounding very well, but others can only become accustomed 
to it from considering; its beneficial results. If the motions of stranp;linor 
are not severe, we need not be disturbed by them, but if there is vomit- 
ing, we must at once withdraw the sound in order that there may be 
no choking. A slight spasm of the glottis and momentary arrest of 
breathing have no significance, yet attention is called to the second 
paragraph below. On the other hand, it is disagreeable if the point 
of stenosis bleeds during the sounding. The procedure can only be 
repeated with care after an interval of several days. In most cases of 
this kind the sounding must be abandoned. 

We sometimes meet with a resistance ^Nhich is not pathological : i. 
At the posterior wall of the throat, but only with unskilful introduction 
of the sound.^ 2. Sometimes, if the cricoid cartilage of the larynx 
somewhat overlaps the esophagus, the point of the sound strikes 
against it. This is easily passed by withdrawing it a little and then 
pushing it on again. 3. By spasm of the esophagus caused by the 
sound, which disappears soon by waiting. 

The life of a patient may be endangered by several occurrences : 
The introductio7i of the sound into the trachea happens very rarely. At 
any rate, as soon as there is marked difficulty in breathing the sound 
is to be withdrawn. If the patient is able to pronounce ah clearly, 
or if the portion of the sound introduced is longer than the trachea, 
then we know that it has not entered the trachea. Other signs are 
deceptive. A still greater danger is that the wall of the esophagjis may 
be injured or ruptured. This results from narrowing of the canal if it 
has become thin and fragile from a crumbling new formation, or by an 
ulceration, or when an abscess or aneurysm near the esophagus is thus 
perforated. The results of these are either ichorous mediastinitis or 
pleurisy with fatal termination, or, if an aneurysm, with immediately 
fatal hemorrhage. We must never employ force if the sound meets with 
resistance. If there is the suspicion of an aneurysm founded on an 
examination of the chest, of the blood-vessels, etc., under all circum- 
stances we are to omit using the sound. 

Examination with the sound gives information in the following ways : 

I. SomtXArnQS 2i deep-seated pain occurs after the examination has 
been made several times, although the sound has only been introduced 
a certain distance and it has not met with any resistance. It may 
depend upon inflammation in that neighborhood,^ upon an ulcer, a 
carcinoma not causing stenosis, a purulent esophagitis, or periesoph- 
agitis. 

^ See Sounding the Stomach. ^ See above. 

3 For determining its height, see under Stenosis. 



266 



SPECIAL DIAGNOSIS. 



2. The sound meets with resistance. Then the patient in many- 
cases is sensible of pressure or has a sensation of pain ; sometimes 
there is severe strangulation. We move the sound back and forth, and 
endeavor to advance it with very slight pressure. We mount a smaller 
knob upon the whalebone sound or take a thinner rubber one. But 
the smaller the sound the greater the danger, and hence greater caution 
is required in using it. 

If we are at length able to advance it farther, then we feel resistance 
just so long as the knob is in the stenosed portion. After passing the 
narrowed part it again passes easily, but of course meets with resistance 
at the same point as it is withdrawn. In using the rubber sound we 
certainly feel the resistance becoming somewhat less as the stenosis is 
overcome, but in any case the resistance continues so long as the sound 
is in the stenosed part. 

We obtain information : {a) Regarding the situation of a stricture by 
bearing in mind the rules given when referring to the anatomy of the 
parts. W^e introduce the sound as far as the stenosis, note the loca- 
tion, starting from the incisor teeth (by seizing the sound accurately 
with the fingers), draw it out and measure it. 

{U) Regarding the degree and length of the stenosis : we learn the 
former by the thickness of the sound that will just pass the stricture; 
the length of the stricture will best be ascertained by employing whale- 
bone sounds, in that we can mark the place where the incisor teeth 
touch the sound when it enters the stenosis and as it passes through 
the stenosis, and then measure the difference. Also, if there is a double 
stenosis, it is indicated (see Fig. lOo). 






Fig. ioo. — Diagrammatic representation of sounding the esophagus when there is a short, a 

long, and a double stenosis. 



We can learn almost nothing regarding the nature of the stenosis 
unless we should catch in the fenestrum of an India-rubber sound a 
shred of tissue which would enable us to diagnose a carcinoma, or 
unless we should meet with the condition described in the next sec- 
tion (3). 

3. By repeated introduction of the sound we are sometimes able to 
pass it through, but if again we meet with an insuperable obstruction, 
we must be very careful : this points to a diverticulum, though not 
indeed with absolute certainty, since it may be met with in other kinds 
of stenosis. 

4. In a case of stenosis which we have repeatedly examined we 



EXAMINATION OF THE DIGESTIVE APPARATUS. 



267 




Fig. ioi. — a, sounding 
the esophagus when the 
diverticulum is full ; b, 
sounding when the diver- 
ticulum is empty. 



suddenly find ourselves unable to get the smallest sound through 

where it has frequently passed easily. This 

may indicate an obstriictio7i by a foreign body, ^ ^ 

as was the case in one instance under my 

observation which ended fatally, where a 

cherry-stone was found in the stenosis. 

5. Sometimes the sound has an unusually 
extensive lateral movement above the stenosis. 
This indicates a considerable dilatation of the 
esophagus above the point of contraction. Such 
dilatations particularly develop in severe and 
long-existing stenoses. 

Stenoses at the cardia are the consequence 
either of cicatrization or carcinoma. For a 
differential diagnosis we take into consideration, 
first of all, the age of the patient and former 
anamnesis (swallowing some corroding liquid, 
particularly lye). As regards the present con- 
dition, the presence of particles of carcinoma in 
the eye of the sound, or of a tumor perhaps 
in the epigastrium on the left anterior wall of 

the stomach, decides the case as one of carcinoma ; but both of these 
conditions are rare. 

Stenoses above the cardia, in the lower part of the esophagus, are 
generally carcinomatous. If they appear after the fortieth year of life, 
they are almost always of this nature. Nevertheless, of course even 
here we must not overlook a possible finding of particles of tissue 
[which can be examined with the microscope]. 

Farther above, in addition to carcinoma, the diverticula due to 
internal pressure \Pulsionsdivertikel'\ come into consideration. Their 
peculiar signs when examined with the sound have been mentioned 
above. The diagnosis becomes comparatively easy in the part of the 
esophagus which lies in the neck. Here a tumor with greatly varying 
volume indicates a diverticulum due to internal pressure. 

Examination of the neighborhood of the esophagtis — that is, of the 
neck and thorax — is of the greatest importance. We are thus able to 
discover compressing tumors or to exclude them with probability. 
We may aid the diagnosis by giving attention to the larynx and 
observing whether there is a recurrent paralysis, which may exist even 
though the voice be quite clear. Compression of the recurrent nerve 
sometimes occurs in carcinoma of the esophagus, with aneurysm of the 
aorta (particularly the left nerve). Moreover, we take into considera- 
tion the examination of the chest, especially whenever there is any 
evidence of a rupture, as in pleuritis, gangrene of the lungs, rupture 
into the trachea or bronchus, with coughing up of particles of food ; 
pericarditis and emphysema of the skin.^ 

Percussion of the esophagus itself can be of almost no aid. Large 
diverticula in the neck may show dulness, provided they are full. 
Exceptionally, a dilatation above a stenosis of the cardia may be dis- 
covered, if dilated with food, by dulness at the back and to the left, 

^ See Examination of Skin. 



268 



SPECIAL DIAGNOSIS. 



or more rarely to the right, of the spinal column from the lower 
boundary of the lung toward the middle of the scapula. 

Auscultation of the esophagus has no independent diagnostic value. 

Swalloivhig. — Normally, the morsels of food or the liquid to be 
swallowed, after reaching the root of the tongue, are pressed or squirted 
very energetically into the esophagus by the contractions of the mylo- 
hyoids, hyoglossi, and of the constrictor pharyngis, while the palate 
and tongue close the exit upward. The morsels pass through the 
esophagus itself without difficulty, whilst the passage of larger morsels 
through the cardia is probably assisted by the muscles of the esophagus. 
Corresponding with the moment of swallowing, there is produced a 
primary noise, and about five seconds later, during the passage through 
the cardia, a second noise. The first sound has been called by the not 
very elegant name of squirting noise, the second the pressing noise. 

The first sound is heard most distinctly at the pit of the stomach to 
the left of the xiphoid process, and also at the same level on the back 
to the right and left of the spinal column. It is heard also farther 
upward, particularly on the back, but here it often becomes an unchar- 
This noise is without any diagnostic value^ 



acteristic 



clucking. 



because in health it is unequally distinct, and it may also be absent. 

The pressing noise [the second sound], however, is heard rather 
constantly in health at the above-mentioned places, which correspond 
with the cardia. But it is absent if there exists a considerable stenosis 
at the cardia or above it. 

Esopliagoscopy has hitherto not given results which compensate for 
the considerable inconveniences for the patient which are connected 
with the different methods at present in use. We therefore think it is 
better to omit it for the present. 



EXAMINATION OF THE STOMACH. 

Topography of the Abdomen. — This is represented in the ac- 
companying figure. We form the different sections by prolonging the 
mammillary lines (or a line which passes from the middle of Poupart's 
ligament upon each side) ; also by lines which, in the upright position, 
are drawn through the ends of the eleventh ribs and through the 
anterior superior spines of the ilii. By these latter fines the section 
lying between the mammillary lines is divided into the epigastrium, 
mesogastriuni, and hypogastrium. It is further to be added that the 
region directly over Poupart's ligament, which extends inward toward 
the symphysis pubis and outward somewhat over the middle of the 
ligament, is called the inguinal region, and the territory below the ends 
of the ribs the hypochondrium. So far as the abdominal contents are 
parietal, their relations to the separate regions of the abdomen are 
plainly indicated in the accompanying figure. 

Anatomy of the Stomach. — Only a little more than the pyloric 
portion [one-sixth] of the stomach lies in the right half of the body, the 
rest [five-sixths] being on the left of the median line. It slopes obliquely 
from the left downward toward the right, so that the cardia is about 
behind the sternal insertion of the seventh rib, the pylorus between the 
right sternal and parasternal lines, on a level with the apex of the 



EXAMINATION OF THE DIGESTIVE APPARATUS. 



269 



xiphoid cartilage. The fundus— t\iQ portion situated the highest, cHng- 
ing to the left side of the dome of the diaphragm — rises as high as the 
fourth intercostal space. The lesser curvature forms a bow with its 



Right mammillary line. 



Left mammillary line. 




Fig. 102. — Position of the abdominal contents. 

CA, ascending colon ; CD, descending colon ; RJ-C, ileo-cecal region ; RJ, inguinal region ; RHs, left hypo- 
chondrium; ^^.epigastrium; i?^, umbilical region; //■, hypogastrium ; F', bladder. 

convexity disposed obliquely downward toward the left. It, with the 
cardia and pylorus, which it connects, lies more posteriorly, covered 
by the liver, while tlie greater curvature extends forward toward the 
abdominal wall, so that a line drawn from the lowest point of the 
lesser to the lowest point of the greater curvature would incline for- 
ward and downward. The situation of the greater curvature varies 
very much with the degree of distention of the stomach. In health, 
however, it only very exceptionally extends to the umbilicus. 

The fundus of the stomach is adjacent to the diaphragm, the spleen, 
and the left kidney ; its greater curvature and also the lower part of 
its posterior surface to the transverse colon ; the pylorus, lesser curva- 
ture, and that portion of its anterior surface which is near to these to 
the left lobe of the liver. Behind and above the stomach, situated at 
the upper part of its posterior surface, is the sinus of the peritoneal 
cavity, the bursa omentalis (pathologically not unimportant), and also 
the pancreas. 



70 



SPECIAL DIAGNOSIS. 



When the stomach is moderately distended a part of the anterior 
surface and the greater curvature are parietal, so far as they are not 
prevented by the lung or heart from above, or by the spleen on the 
left, and by the left lobe of the liver on the right. That part of the 
parietal surface of the stomach which is covered by the left lower por- 
tion of the ribs comprises the important region to which Traube gave 
the name of " halfmoon-shaped spaced We see from this description 
that with moderate distention only a small part of the healthy stomach 
can be directly examined. The most important parts, the cardia and 
pylorus, are bent deeply in. But we have a favorable moment for 
examining the latter in certain pathological conditions, where it is 
desirable to be able to judge of it, it being often pushed down with 
the lesser curvature below the Hver. 

Inspection and Palpation of the Stomach. — There is scarcely 
any place where inspection and palpation are so closely connected as at 
the abdomen, and especially the stomach. The patient is placed so as 
to lie comfortably, with the upper portion of the body moderately 
raised. We look at the region of the stomach with the greatest care, 
illuminating it from all possible directions : then palpate with the tips 
of the first, second, and third fingers, and thus notice first the tender- 
ness (always at first proceeding very cautiously), then the objective 
condition ; finally completing the palpation with inspection, or vice 
versa. 

The result of the two methods of examination will be affected by 
several factors — by the size, sharpness of the boundaries, and density 
(resistance) which we discover in the abdominal wall, and its condition. 
As regards the latter, it is important for the examiner to avoid causing 
contraction of the abdominal muscles by having the patient in the 
recumbent posture, cautioning him to keep the muscles lax, and by 
proceeding slowly with the palpation, the hands being warmed. Con- 
traction of the recti abdominales, with their short tumor-like sections of 
muscle, may very much disturb, or even deceive, one in making an 
examination. As to the general thickness of the abdominal walls in 
chronic diseases of the stomach, especially if very severe, this is very 
much lessened by wasting — a condition favorable for making an exam- 
ination. 

The normal stomach cannot at all distinctly be recognized or 
defined through the abdominal wall. It can only exceptionally be 
done when there is extreme emaciation. 

Not infrequently there are cases where, in extremely wasted females 
with very lax walls, the greater curvature and peristalsis of the anterior 
wall of the stomach could be clearly seen. In these cases the autopsy 
shows a normal condition of the stomach. 

On the other hand, tlic healtJiy stomach, distended with food or 
gas, sometimes enables us to imagine its condition by the projection in 
the epigastrium, and still more by a high halfmoon-shaped space — that 
is, by tympanitic resonance over the left lower lobe of the lung in the 
side.^ We can sharply bound a healthy stomach only in individual 
cases when it is inflated with gas.^ Thus, it has been found that the 
greater curvature of a normal stomach, when very greatly distended, 

1 See under Percussion. 2 g^g Method of Procedure, p. 271. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 27 1 

may reach as far as the umbiHcus. Of course we cannot ascertain the 
location of the lesser curvature if the stomach is in its normal position. 
Moreover, the distensibility of the healthy stomach varies very much 
with different persons, so that on trial one person earlier, and another 
later, has difficulty, especially oppression, which marks the limit of 
distention. 

The chief pathological signs furnished by the stomach are : its dis- 
tention or displacement, its thickness, and amount of peristaltic action 
of its walls, also signs of circumscribed tumors in its walls. Other 
important signs are to be added to those already mentioned. Pain 
upon pressure during palpation requires a special description. 

Distention is more or less distinctly made out by inspection and 
palpation, according to its extent and the thinness of the abdominal 
walls. But it may also entirely elude examination. In favorable cases 
we can see and feel (easily when looking down from the patient's head) 
the greater curvature. To a varying extent it moves down, often below 
the umbilicus, more rarely nearly to the symphysis, and in so doing it 
shows the bend toward the left. The position of the greater curvature 
of course varies with the degree of fulness of the stomach, but usually, 
unless artificially emptied,^ as by emesis or the stomach-pump, it does 
not come up above the umbilicus. At the same time the pyloric por- 
tion very often has a peculiar behavior w^hich influences the whole sit- 
uation of the stomach and renders the pylorus as well as the lesser 
curvature accessible for examination. When the stomach, for the time 
being, is distended by a large quantity of food, in the upright position 
of the patient it pulls the pylorus forward from under the liver, and 
with it, under some circumstances, the lesser curvature. This, in rare 
cases, is seen in the upper epigastrium, in a line convex downward 
(when the light falls from the foot of the bed), when sometimes it may 
even be felt. Also the portio pylojnca and even the normal pylorus 
may be felt.^ In consequence of this displacement of the pylorus the 
whole stomach slopes more strongly downward toward the right. 

In rare cases the pylorus has this low down position, without there 
being any dilatation of the stomach. The condition is congenital or 
caused by strong adhesions (Kussmaul). 

As has already been mentioned, the distinctness with which the 
figure of the stomach can be made out is largely influenced by the 
extent of its fulness. Hence, for the purpose of making the examina- 
tion we must artificially distend it (Frerichs). Until very recently this 
was always done with carbonic acid, by giving the patient as much as 
two teaspoonfuls of tartaric acid and bicarbonate of soda dissolved in a 
little water. The gas quickly develops in the stomach, and demon- 
strates clearly the situation and size of the organ, rendering the exami- 
nation of its walls easy.^ But this procedure sometimes gives rise to a 
feeling of oppression, and even of symptoms of collapse. Recently 
there has been devised a method of inflating the stomach which is much 
more to be recommended, because the amount of gas for distending the 
stomach can be regulated exactly, and, if necessary, it can be emptied 
out in an instant. A soft stomach-tube is introduced (just as in sound- 

^ See under Contents of the Stomach. ^ See under Tumors. 

2 See under Peristalsis and Hypertrophy, 



2/2 



SPECIAL DIAGNOSIS. 



ing the esophagus), and then the stomach is inflated with air through 
the tube by means of an India-rubber ball, introducing as much as is 
necessary or as the patient can bear. At any time the air can imme- 
diately be let out through the tube. 

By inflating the stomach the so-called hour-glass stomacli can be 
easily recognized during life (twice it was formed by a scar which 
strictured it in the middle). In the same way we can discover that the 
pylorus does not close, by the fact that the gas blown in does not dis- 
tend the stomach, but immediately enters the small intestine. 

Von Ziemssen still gives the preference to distention with carbonic 
acid — a method which we will not omit to mention. In his last com- 
munication he gives the proportions for adult men as 7 grams of bicar- 
bonate of soda and 6 grams of tartaric acid ; for adult women i gram 
less of each. 

The sound may be employed in the same way as with the esophagus 
to determine stenosis at the cardia due to cancer. (The employment 
of a hard English esophageal sound for ascertaining the size of the 
stomach [Leube] is scarcely to be recommended. The sound is intro- 
duced into the stomach, and pushed on until it meets resistance at the 
greater curvature, and then we ascertain where the end of the sound is 
by palpation from without.) 

Regarding palpation by striking and the resulting splashing, see 
under Auscultation. In the neighborhood of the stomach we may 
have epigastric pulsation,^ liver-pulse;^ lastly, it may be communicated 
from the aorta or from aneurysm of the abdominal aorta. With tumors 
of the stomach the pulsation from the aorta is usually very distinctly 
transmitted. 

Increased resistance ; peristaltic motions. The former occurs simul- 
taneously with the general distention of the stomach in consequence of 
the hypertrophy of the muscular portion which generally accompanies 
dilatation of the stomach. Hence it is an indirect sign of dilatation. If 
it is found within a limited area, as in the right half of the epigastrium, 
even if it is not sharply defined it may indicate carcinoma. We must 
be careful not to confound it with contraction of one of the bellies of 
the rectus abdominis. Peristaltic motions which can be felt as well 
as seen are very important, being often the first signs of an hyper- 
trophy, and thus a dilatation. By their situation and extent they may 
also indicate the size of the stomach. It is very rare for them to occur 
without dilatation: only in nervous "peristaltic unrest" of the stomach 
(Kussmaul). Generally they extend in the normal direction from the 
fundus to the pyloric region. But sometimes, and that in marked 
pyloric stenosis, they are reversed — antiperistalsis. They will often be 
excited or increased by gentle strokes and by faradization ; sometimes 
by irritation of the skin, as by simply uncovering it. With very lean 
persons we must think of the possibility of there being, under some 
conditions, intestinal peristalsis. 

Tumors in the region of the stomach are often only to be felt, not 
seen. They cannot be demonstrated if connected with a part of the 
stomach that is not parietal — cardia, lesser curvature, posterior wall of 
the stomach, commencing cancer of the pylorus. These tumors are 



1 See p. 177, 



2 See pp. 221 and 228. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 273 

most frequently cancer of the stomach (more rarely a dense scar from 
ulcer), and are most often located to the right of the middle line, 
because they belong to the portio pylorica or to the pylorus itself In 
the latter case they can generally only be felt when the pylorus is 
pushed downward, as has already been mentioned. Carcinoma usually 
feels uneven and dense. Less frequently it is smooth, and can then 
easily be overlooked or be mistaken for a belly of the rectus.^ Pro- 
jection of the stomach during deep breathing, as a result of the move- 
ments of the diaphragm, usually does not take place at all, for the 
reason that the stomach is not a soHd body. We observe a slight, or 
possibly a marked, respiratory displacement when there is adhesion of 
the distended pylorus and the liver,^ or if there is a tumor which 
extends from the subphrenic region to a parietal portion of the stom- 
ach. Dense scars from ulcers and the infrequent hypertrophy of the 
pylorus, also soHd bodies that have been swallowed, may feel Hke 
tumors. Mistaking them for scybala in the transverse colonels not 
likely to happen. 

In all diseases of the stomach tenderness during palpation may be 
wanting. It is absent least frequently with ulcer of the stomach. If 
there is pain, it may vary very much : in acute catarrh of the stomach, 
also sometimes in chronic, it is dull and quite diffuse ; with ulcer it is 
often very much circumscribed, limited to a spot the size of a dime, ex- 
tremely severe, often shooting through to the back, especially toward the 
left ; in carcinoma there is sometimes a marked insensibility, sometimes 
a more diffuse, sometimes a narrowly-defined, pain of variable intensity. 

A constant circnniscribed tenderness in the gastric region and se- 
vere spontaneous pain, which are markedly increased by movements 
of the body, according to the observations of Landerer, may also be 
produced by adhesions of the stomach or omentum to the abdominal 
wall. The cause of the adhesion in such cases is most probably a 
former ulcus ventricuH or a former circumscribed trauma. Such cases 
are very difficult to distinguish from nervous cardialgia or splanchnic 
neuralgia. 

Percussion of the Stomach. — This applies to that portion of the 
anterior wall of the stomach which lies against the abdomen and the 
anterior (left lower) wall of the thorax. It yields, in much the greater 
majority of cases, a very deep tympanitic sound, and sometimes, when 
there is marked tension of the stomach, a clear non-tympanitic sound. 
If the stomach contains a considerable amount of food, it may, in part 
(especially in standing), have an absolutely dull sound. But we hardly 
ever find it dull throughout the whole extent of that portion of the 
stomach that is parietal, because it almost always contains considerable 
gas as well as food. The tympanitic as well as the non-tympanitic 
stomach-sound frequently has a metallic quality. 

The boiuidaries of the stomach are determined by topographical per- 
cussion (see Fig. 103). They are as follows : 

On the side toward the liver there is a dull sound ; it is often dif- 
ficult to make out because the border of the liver is thin.^ On the side 
toward the lung there is a non-tympanitic, clear sound. Here it is 

1 See under Resistance. 2 gee this. ^ See Intestine. 

* See Percussion of the Liver. 
18 



274 



SPECIAL DIAGNOSIS. 



often difficult to mark sharply the boundary-line, on account of the 
thinness of the border of the lung and the similarity of the two sounds. 

Sometimes we have to distinguish a boundary of the stomach from 
the heart, should the apex of the latter reach farther toward the left 
than the liver; sometimes from the spleen if the stomach should be 
stretched out somewhat. We can separate it from the large and small 
intestines, both of which give a tympanitic sound. 

Except these last named the boundary-lines are all dependent upon 
the situation and size of the surrounding organs. Therefore, and 
because there are no true boundary-lines for the stomach, except its 
parietal boundaries, we do not employ percussion for the stomach. 




Fig. 103. — Percussion boundary of the lungs in front (Weil). 

g, h, the upper boundary of the lungs ; e,/", the lower boundary' of the lungs ; b, d, boundary between the 
lung and heart at the incisura cardiaca. The darkly-hatched surface represents the portions of the heart and 
liver that are in contact with the chest-wall ; the light hatching, the so-called relative heart- and liver-dead- 
ness (see later), vi, spleen-deadness ; n, the average position of the lower boundary of the stomach. 



The only real boundary is that on the side toward the intestine, which 
gives the situation of the greater curvature. 

But it is almost always very difficult to determine this line (there 
being a tympanitic sound on both sides of it, with only a difference in 
pitch). We can hardly even maintain its correctness without the aid 
of inspection and palpation. Thus, percussion of the stomach, for the 
great majority of cases, has an extremely doubtful value. 

On the whole, we get the best results from percussion in health, and 
particularly when the stomach has been artificially dilated. With the 
former we then find that the greater curvature usually is somewhat 
above the umbilicus, sometimes reaching beyond it. When the stom- 
ach is moderately full it commonly stands below the umbilicus, between 
the apex of the xiphoid process and the umbilicus. If the stomach is 



EXAMINATION OF THE DIGESTIVE APPARATUS. 275 

dilated, the boundary is lower down/ Likewise, should the lesser 
curvature be lower down, it can be made out by the aid of percussion. 

Another procedure, but one which is not always successful, is first 
to empty the stomach as much as possible,^ then to percuss the 
abdomen, the patient being in the standing position. Usually we 
do not find any boundary for the stomach. Then we have the 
patient drink freely, and again percuss while he is standing. In the 
lower part of the stomach, hence above the greater curvature, about in 
the middle line, we shall find a dulness which indicates the situation of 
the greater curvature, and thus a possible dilatation may be recognized 
(modified after Penzoldt). This dulness may sometimes be directly 
proved, without any preliminary procedure, if the stomach is partly 
filled with fluid. The dulness disappears when the patient lies 
down. 

There is distinct dulness with tumors of the stomach (strong per- 
cussion) only when they are very thick, and this is not often the case. 
Hence they usually give stomach-resonance. But tumors of the liver 
and spleen, on the other hand, almost always are dull because they are 
larger. Yet this difference is not an entirely sure sign. 

Rod-pleximeter percussion^ over the stomach usually gives a beauti- 
ful silver tone. It is employed for determining the boundary under the 
supposition that in this way the person who is listening over the stom- 
ach must hear the high silver tone just so long as his assistant per- 
cusses over the stomach ; but the result of this procedure is hardly 
ever positive enough to give it value. 

That part of the left lower lobe of the lung is designated as the 
^'circular stomach-lung space',' where a tympanitic sound may be 
heard with strong percussion (Ferber). We may likewise speak of a 
" circular stomach-liver space," sometimes even of a " stomach-heart 
space." ^ None of these have any value for exactly determining the 
size of the stomach. 

The Halfmoon-shaped Space (Traube).— This is the name 
given to that portion of the lower left part of the thorax which lies 
below the lung (or heart), between the liver and spleen, and, as a rule, 
in health gives a tympanitic sound, most frequently a stomach-sound, 
but not infrequently also an intestinal sound, or both. It is discovered 
by gentle percussion. Occasionally, in health, we here find dulness 
instead of tympanites, and then only when the stomach is decidedly 
full, or when the full transverse colon is here parietal, or when the 
greater omentum is unusually loaded with fat (Weil). 

In enlargement of the liver, of the left heart, or of the spleen 
this space will always be found correspondingly smaller. But its 
behavior in certain conditions of the left lung or of the left pleura is 
of especial diagnostic interest. Exudation in the left pleura usually 
causes dulness correspondingly early in the upper portion of this space 
in that it first collects in the complementary pleural sinus. As the ex- 
udation increases, the halfmoon-shaped space diminishes more and 
more, the dulness sometimes extending as far as the bend of the ribs, 
depending upon the amount of downward pressure of the diaphragm, 
unless there are pleuritic adhesions in the pleural sinus, in which case 

^ See Inspection, Palpation, ^ ggg Emesis. ' See p. 117. * See p. 179. 



2/6 SPECIAL DIAGNOSIS. 

we do not have the space diminished. As the pleuritic exudation is 
absorbed the space resumes its normal proportions, and if there is 
shrinking after the absorption, it becomes greater than normal, for the 
reason that the lower border of the lungs does not again come down 
to its former place, and, on the other hand, the diaphragm stands 
higher. Rarely, with pneumonia of the whole left lung or its lower 
lobe the halfmoon-shaped space becomes very slightly smaller as a 
result of the enlargement of the lung during hepatization, and also, 
probably, from a small pleuritic exudation. 

It is to be observed that in acute disease of the left half of the 
chest an early distinct diminution of the halfmoon-shaped space is 
made manifest by a certain degree of dulness ; a marked diminution of 
the space indicates, almost to a certainty, a pleuritic exudation ; and if 
there is extensive dulness in the left half of the chest, if the differential 
diagnosis between pneumonia and pleurisy is uncertain, then a decided 
diminution in the size of the space speaks with strong emphasis in 
favor of the latter. 

Auscultation of the Stomach. — This has value in only one 
direction, but that is not to be undervalued. When palpation is 
made by strokes upon the region of the stomach, striking more or less 
strongly, according to the sensibility of the patient, very short blows 
with the tips of the fingers, sometimes spontaneously, and again only 
with the strokes, we hear a splashing which is loud enough to be 
heard at a distance. This results from a certain relation between the 
fluid and the gas in the stomach even in health, but very much more 
frequently in dilatation. Hence in making a careful examination of the 
stomach we must always employ it. In itself it does not indicate any- 
thing, even though it is often found when the examination is frequently 
repeated. 

Such a splashing sound or a similar one may also have its origin in 
the intestines and even in the peritoneal cavity. As an intestinal sound 
it is heard in profuse diarrhea, most markedly in cholera ; also some- 
times in intestinal occlusion. From the peritoneal cavity a somewhat 
similar sound may be heard in circumscribed perforating peritonitis, 
particularly in subphrenic abscess.^ 

If we apply the ear when the stomach is inflated with carbonic acid, 
we shall hear a loud seething. We can recognize the same thing, but 
less distinctly, in dilatation of the stomach with fermentation of its 
contents. 

Illumination of the Stomach ; Gastro-diaphanoscopy. — The 
first method applicable in man by which an illuminating body, visible 
through the abdominal wall, could be introduced into the stomach, was 
devised by Einhorn in 1889. Einhorn's instrument is a stomach-tube 
which carries on its lower end an incandescent lamp surrounded by a 
glass shade. The conducting wires go through the interior of the hol- 
low sound. This illuminating sound can be introduced into the stom- 
ach like any other stomach-sound, and the illumination effected by turn- 
ing on the current without injury to the stomach, whether it be full or 
empty, for the amount of heat is very slight. The diagnostic results of 
diaphanoscopy are greatly heightened if a considerable quantity of 

^ See this. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 277 

water (up to 1500 c.c.) is introduced before or during the examination 
This may be done with the illuminating sound itself if an aperture is 
made in it directly above the lamp (Kuttner). 

The illumination may bring into view apart of the greater curvature, 
and in gastroptosis also a part of the lesser, and also tumors located 
in the anterior wall may be perceived as dark places in the illuminated 
region. An important result of the method seems to be that the 
normal as well as the dilated stomach appears considerably larger if 
filled with water than has been hitherto supposed. Sources of error, 
as the illumination of neighboring intestinal coils filled with water and 
gas, it must be borne in mind, are not excluded. 

I have no personal experience with the method, and therefore re- 
specting the details refer to the writings of Kuttner^ and Meltzing.^ 
Whether diaphanoscopy really gives considerably better results than a 
carefully made examination of the stomach by inflation and percussion 
in a standing position certainly seems to me still doubtful, according to 
the results of these investigations. 

Remark. — It is evident from the above that very often anatomical 
diseases of the stomach exist without any physical signs. Conse- 
quently, their differential diagnosis from nervous cardialgias and from 
some forms of nervous dyspepsia is frequently very difficult. In 
general, a certain uniformity of stomach complaints and their increase 
by moderate exercise of the body points to an anatomical disease. 
Most frequently, however, a positive differential diagnosis can be made 
by an investigation of the functions of the stomach. Therefore the 
examination of the motive-power of the stoinacJi during digestion and a 
chemical examination of its contents frequently give much more im- 
portant conclusions than the local examination. Therefore especial 
attention is called to the former. 

EXAMINATION OF THE INTESTINES. 

Inspection and Palpation. — In employing the former there 
must of course be illumination. The patient being in the dorsal posi- 
tion, we inspect the trunk, as a whole, from a distance ; in detail, close 
at hand, palpating with a warm hand. Then, carefully grasping a part, 
we notice always first as to the amount of tenderness, when, if there is 
any suspicion of simulation or exaggeration, it is best not to ask 
whether we are causing pain, but simply to notice the result of 
moderate and also stronger pressure. After completing the first 
examination, which gives one the bearings of the case, inspection and 
palpation go, hand in hand, very closely together ; for this reason we 
speak of them together. 

Pain Produced by Pressure [Tenderness']. — A diffuse dull pain often 
occurs with intestinal catarrh. A like diffuse, but generally an ex- 
tremely severe, pain is observed with acute general peritojiitis. Cir- 
cumscribed tenderness is especially frequent in the right iliac fossa. It 
is often quite marked in abdominal typhus [typhoid fever], often more 
severe in intestinal tuberctdosis, moderately severe in typhlitis and affec- 
tions of the vermiform appendix, in both of the last-named diseases 

^ Berline}- klin. Wochensch., 1893. '^ Zeitschr.f. klin. Med., Bd. 27. 



278 SPECIAL DIAGNOSIS. 

generally (not always) in connection with other local signs.^ Pain in 
the left iliac fossa is connected with the descending colon (especially 
dysentery). Very circumscribed severe pain at shifting points may 
occur with a circumscribed affection of the small intestine, as invagina- 
tion - (intestinal tuberculosis). The seats of hernia require very espe- 
cial attention. (Works upon surgery are to be consulted regarding these.) 
It is to be further remarked that pain in the abdomen, according to its 
location, may come from any of the organs contained in its cavity, and 
also from its walls ; from the anterior abdominal wall (abscess) ; pain 
in the iliac regions from the hollow of the sacrum (inflammation, 
tumors) ; pains in the same place and in the lumbar region from 
psoas abscess. 

The dimensions of the abdomen may be increased : by a layer of 
fat ; by gas in the intestines (intestinal meteorism, tympanites), as it 
occurs continually, scarcely pathologically, after hearty eating, often 
with a large development of fat ; but we may also have it in every 
variety of degree as a pathological condition : in acute and chronic 
catarrh of the intestine, intestinal stenosis, in acute and chronic perito- 
nitis, and in abdominal typhus [typhoid fever], where it is often of 
diagnostic value. According to the amount of distention the abdomen 
is more or less full, which changes its normal soft condition to one of 
marked resistance. When there is marked meteorism the liver and 
diaphragm are pressed upon, and by the latter the lungs and heart are 
pressed upward. 

In a case of typhus abdominalis [typhoid fever] I once saw an exten- 
sive inflammatory undermining of the abdominal wall, which very 
closely simulated meteorism by considerably distending the abdomen, 
which proved to be an abscess in the abdominal muscle. (For disten- 
tion of the abdomen with fluid or air in the peritoneal sac, see 
Peritoneum.) 

There may be circumscribed distention of the abdomen from a great 
variety of causes : most frequently from some condition in the peri- 
toneum.^ In chronically developing stenosis due to tumors or in acute 
incarceration it is produced in the intestines themselves ; the piece of 
intestine immediately above the stenosis becomes distended. The cor- 
rect diagnosis of such a circumscribed inflated piece of intestine is of 
great clinical significance, and must be sought for in every possible 
way. The chief point is to take time for inspection and Hkewise for 
palpation, observing carefully whether the flatulent portion is completely 
at rest or whether there is peristalsis,* whether the swelling changes its 
position in its entirety or not, or whether it is sometimes flatter or dis- 
appears altogether. Palpation and percussion give uncertain results ; 
they may, however, particularly the former, sometimes serve to confirm 
what the eye has discovered. 

Dimijtished volume of the abdomen (drawing-in, sinking-in) results 
from an insufficient amount of nourishment from any cause (especially 
from diseases of the esophagus, pyloric stenosis, any cachexia — in 
short, from any disease that requires (or results in) restricted diet. 
Usually this condition is more especially manifested by the absence of 

^ See below, 2 g^g Palpation. 

' Which see, and also the next page under Tumors. * See this. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 279 

fat and wasting of the abdominal muscles. A particularly marked — 
the so-called " scaphoid drawing-in " — probably related to an active 
contraction of the abdominal muscles, occurs in meningitis, particularly 
basilar, and in lead-coHc. 

Intestinal peristalsis exceptionally can be seen when the abdominal 
wall is very thin and lax. It occurs almost exclusively in women who 
have had children (particularly if there is a separation of the recti mus- 
cles). On account of its similarity, it is to be distinguished from what 
is described below as pathological peristalsis only by the absence of 
other phenomena and by the narrowness of the intestinal figure. 

Pathological peristalsis is an important visible and palpable sign of 
stenosis of the intestine, and occurs in the portion of intestine above the 
stenosis. We observe a round projection, with the slow motions of a 
worm, now disappearing and often immediately reappearing in a spot 
not far distant, so that we have the phenomenon of peristalsis. The 
intestine, as it becomes prominent, is moderately resistant and is often 
distinctly distended. [During the instant of greatest distention the 
prominence is more distinctly tympanitic] The resistance may become 
greater in chronic stenosis of the intestine with hypertrophy. Some- 
times the last swelling — that is, the one just above the point of stenosis 
— is the largest, and subsides with a loud cooing or bursting sound. 
This phenomenon may have a very great variety of manifestations, 
generally with a pressing, choking pain, and it may manifest itself under 
gentle blows, with faradization, or even by merely exposing the surface 
to the air. It is usually very difficult to draw any conclusion regarding 
the portion of the intestine involved by the location of the phenomenon 
or the direction of the peristalsis. On account of its thickness we are 
apt to mistake a dilated loop of small intestine for a portion of the 
colon. 

Circumscribed tumors of the intestine are always felt before they can 
be seen. They may be — i. Balls of feces, scybala, in the large intes- 
tine, often recognized by being arranged in a circular form, by their 
location (which is often deceptive), or by their retaining an indentation. 
Sometimes we are only able to be positive regarding their nature by 
their disappearance after free purgation. 2. Tumors of the intestine are 
either new formations, which are generally very firm, uneven, or they 
result from invagination of one portion of the small intestine into 
another or into the large intestine, which form round vermiform tumors. 
The former are entirely fixed, the latter may suddenly disappear. Both 
may be connected with signs of stenosis of the intestine. If they be- 
long to the small intestine, they usually more or less change their 
location. (For distinguishing these tumors from those of the other 
abdominal organs, of the peritoneum, and of the abdominal wall, see 
below. For inflammatory tumors of the intestine, perityphlitis, etc., 
see Peritoneum.) 

Tumors of the rectum^ cannot be recognized from the abdomen. 
Those at the point of union between the transverse and the descending 
colon are often recognized late because they lie concealed. They may 
easily be confounded with tumors of the spleen or with the kidneys.^ 
In this connection we must bear in mind the phenomena of stenosis. 

1 For these, see below. ^ See these. 



28o SPECIAL DIAGNOSIS. 

For peritoneal friction-sounds, see Peritoneum ; for cooing sounds 
that can be felt, see Auscultation of the Intestine. 

Palpation of the Rectum. — The rectum must be examined with the 
finder if the movement of the bowels or the character of the stools 

o 

indicates disease of this organ, or if disease in the neighborhood (as the 
wall of the true pelvis, the prostate, or the seminal vesicles in men, the 
uterus and its annexae in women) is suspected. In making the exam- 
ination we first obtain a view of the anus externally. The anus is to 
be examined for varices, changes in the mucous membrane, etc., and 
its neighborhood for signs of syphilis, rectal fistula, etc. Sometimes it 
is also necessary to obtain a thorough emptying of the bowel before- 
hand. The index finger is to be oiled, and introduced with the patient 
either lying on the side or back.^ When the rectal sound is employed 
in order to reach a stenosis beyond the reach of the finger, the greatest 
care is necessary. It is best to employ a sound open at the end, so as 
to throw in some lukewarm water by means of an irrigator — a pro- 
ceeding by which any obstruction to the passing of the sound may be 
gotten out of the way. Sometimes a large quantity of water is thus 
employed, as recommended by Hegar (see also the works upon surgery 
for the employment of the mirror in making the examination). 

Distending the descending colon by inflating it with air introduced 
from the anus through the sound, if carefully done, is not dangerous, 
and is very strongly recommended for determining the location of the 
colon with reference to other organs, tumors,^ the figure and con- 
dition of the colon itself When there is a suspicion of a stomach- 
colon fistula, sometimes a positive diagnosis may be made by this 
method if it is noticed that the stomach unmistakably presses forward 
in connection with the colon. If this phenomenon is absent, a stomach- 
colon fistula cannot with certainty be excluded, because the passage of 
air from the colon into the stomach may be absent if the fistula be 
small or its orifice closes like a valve. 

Percussion of the Intestine.— Generally the intestine gives a 
tympanitic sound ; with meteorism with great tension it may become 
clear, non-tympanitic. Over large intestinal loops and also over the 
stomach (with like tension) the sound is deeper than over narrow 
portions ; over lax portions it is deeper than over those under strong 
tension. But we can hardly ever determine as to the width of any 
portion of intestine by the resonance, chiefly because of the influence 
of tension, which, for a single loop of intestine, we cannot at all con- 
trol. Hence we cannot with certainty determine by percussioi the 
boundary between the colon and small intestine, a dilatation above a 
stenosis from another portion, or intestine from the stomach. At 
most, we can only determine the boundary of the descending colon by 
artificially inflating it. 

(For determining by percussion the boundaries of the abdominal 
organs that do not contain air, see under the different ones.) Intestinal 
tumors do not always become so large as to give dulness. In per- 
cussing them we first press tolerably deeply with the finger used as a 
pleximeter, and if we do not find dulness, we press still deeper, in order 

^ For examining during narcosis by introducing the whole hand, see works upon Surgery. 
^ See Spleen, Kidneys. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 28 1 

that we may push aside any fold of intestine that may lie oyer the 
tumor (" deep percussion " — Weil). 

Auscultation of the Intestine. — Grumbling sounds and splash- 
ings, which may often be heard at a distance {Bordo?ygiui), and are in 
themselves very troublesome (especially in women who have had chil- 
dren), do not have any further significance. A loud cooing is not with- 
out diagnostic value if it occurs at the close of an attack of pain like 
strangulation. Even if we cannot see any intestinal peristalsis, we must 
remember the possibility of stenosis of the intestine. 

Although formerly too much importance was attached to it, yet 
there is some diagnostic value in the cooing, which is more frequently 
felt than heard in the ileo-cecal region in typhoid fever (ileo-cecal 

-.qline). 

EXAMINATION OF THE PERITONEUM. 

Pathological conditions of the peritoneum are, in part, of such a 
character that they affect the outer layers, the coverings of the other 
abdominal viscera; hence possible anomahes of the peritoneum may be 
overlooked in the direct examination. Thus, very many diseases of 
other abdominal organs are combined with those of the peritoneum. 
This fact and the anatomical interrelations of the diaphragm and 
certain other organs make it very difficult to give a separate descrip- 
tion of its physical diagnosis. In what follows we mention ^vhat may 
be learned in peritoneal diseases by the separate methods of examina- 
tion, but we call attention to the point that the examiner ought to 
learn to give his attention to all the abdominal organs, by inspection, 
palpation, etc., at the same time. 

Inspection of the Abdomen. — In diseases of the peritoneum this 
may reveal distention of tlie abdomen, which may be quite considerable 
and quite like intestinal meteorism. Meteorisnius peritonei — that is, 
escape of air into the abdominal cavity from the intestine or stomach 
— is a very serious condition which always results in peritonitis.^ 

There is general, though often unequal, distention when there is 
freely-movable fluid in the peritoneal cavity — ascites. Such a fluid 
effusion collects in the most dependent part of the abdominal cavity — 
first in the true pelvis ; then, as the amount increases, it rises higher, 
reaching the abdominal wall, where its level may stand at different 
heights. The abdominal -organs that contain air float upon the top of 
the fluid, so far as the peritoneal fold permits. In consequence of the 
increased internal pressure the abdomen is broader and the lower parts 
contain the fluid, while the small intestine, containing air, generally lies 
at the upper part and is in contact with the abdominal wall. But the 
fluid, since it is freely movable with every change of position of the 
body, always occupies the most dependent part, and, if the tension of 
the abdominal wall is not too great, there often results an unequal dis- 
tention of the abdomen which varies with the position of the body. In 
the dorsal position it is quite toward the sides ; when lying upon the 
side it is over the inguinal and lumbar regions upon each side ; while 
in the sitting posture it fills the dependent abdominal sides, the upper 

^ See below. 



282 SPECIAL DIAGNOSIS. 

portions being empty ; and in standing, the lower part of the abdomen 
projects. If there is so large an effusion as to fill the abdomen very 
full, there is no change in the distention, and it is also more regular, 
like that we have with marked meteorism. (Regarding the high posi- 
tion of the diaphragm when there is distention of the abdomen, see 
Respiratory Organs and Liver.) 

If the skin is examined, when there is marked effusion it will not at 
all look as it usually does : on account of the tension it is smooth, 
shining, and shows, especially in the dependent parts, a peculiar bluish 
shimmer. When the tension is of long standing there are colorless 
streaks or striae which are formed in the skin by the continuous stretch- 
ing, as in the scars resulting from pregnancy, so called from their chief 
cause. The umbihcus may be obliterated or even project. In marked 
ascites the cutaneous veins of the abdomen are found enlarged, since as 
collateral veins they must take up the overflow of the intra-abdominal 
veins, which are compressed. Under some circumstances there may be 
edema of the legs from compression of the iliac veins. (Regarding the 
caput mediiscB and the abdominal veins in general in cirrhosis of the 
liver, see under Liver.) 

Ascites that moves about generally results from transudation into 
the abdominal cavity from stasis, being rarely, except in the beginning 
of a disease, dependent upon inflammatory exudations. In the former 
case it is either a partial indication of general dropsy and connected 
with edema,^ or entirely the result of obstruction of the portal vein 
(cirrhosis of the liver, compression, and thrombosis of the vein). In 
the latter case it is a sign of peritonitis.^ 

Circumscribed distention of the abdomen where there has been little 
or no change in posture may be due to inflammatory fluid exudations, 
which are enclosed between adhesions of the intestine to itself or to the 
abdominal wall, or by any kind of tumor in the abdominal cavity ; and 
also by tumors or abscess in the abdominal wall itself Circumscribed 
distention, with inflammatory redness, indicates a discharge outward of 
an abscess, either fecal or some other collection of pus in the abdominal 
cavity, or of the abdominal wall. 

In diseases of the peritoneum palpation gives very important signs : 
Pain exists in all inflammatory affections. It is usually very severe 
in acnte perito7titis,somQX.\mes so great that the shghtest motion, or even 
the lightest covering upon the abdomen, cannot be borne. This sensi- 
bility is an important indication of peritonitis, especially in distinguish- 
ing the ordinary intestinal meteorism from peritoneal meteorism, some- 
times also in distinguishing inflammatory ascites from dropsical ascites. 
Circumscribed pain may indicate a circumscribed peritonitis, as it occurs 
more particularly over tumors, abscess of the stomach and intestine. 
In chronic peritonitis, especially in tuberculosis, sometimes there is 
entire absence of tenderness. 

Now and then in chronic peritonitis there is a general, more or less 
sym7netrical, Jiardncss of the abdominal wall ; that is to say, it feels as 
if it were thickened. This is to be distinguished from the general 
increased resistance from tension due to marked distention of the 
abdomen from meteorism and ascites. Thus there is a marked differ- 
^ See this. '^ See under Palpation, Percussion. 



f 



EXAMINATION OF THE DIGESTIVE APPARATUS. 283 

ence between the resistance of fluid and that of meteorism in a fold of 
intestine. The latter has more the feeling of an air-pillow, the former 
is more like a material substance. 

But we recognize fluid with much more certainty by the feeling of 
fluctuation^ undulation. A hand is laid flat upon the surface of the 
abdomen, and then the abdominal wall is tapped lightly with one or 
two fingers, just as in direct percussion. If both hands are used, fluc- 
tuation is found in a place where there is an accumulation of fluid, and 
the stroke of the wave is felt with every tap of the fingers. In this way 
the presence of even a small amount of fluid in the abdominal cavity 
can be made out with great certainty. When there is great effusion 
under high pressure this sign may fail. On the other hand, we may 
be deceived in the case of persons who have a large accumulation of 
fat in the abdomen by the trembhng of the layers of fat, and possibly 
also by the fat in the abdominal cavity, especially in the omentum. 

Very much increase of resistance, and thus an indistinct fluctuation^ 
generally occurs when the peritoneal fluid is encysted. 

Circumscribed hard resistance, now like a round ball and again cord- 
like, occurs with extremely great variations in chronic peritonitis, not 
alone of the tubercular variety, but also in the so-called simple perito- 
nitis from inflammatory new formations ; nevertheless, the former is 
usually the much more frequent condition. Particularly often in this, 
although sometimes also in simple chronic peritonitis, we feel above the 
navel a dense transverse string : the omentum is shrunken and thick- 
ened by inflammatory products. Besides, there are usually, but not 
always, the signs of encysted, or even of free, fluid i7i the peritoneal 
cavity. Exactly the same phenomena are present in carcinoma and 
sarcoma of the peritoneum. 

There occurs in an acute way resistance iji the neighborhood of the 
cecum in typhlitis and perityphlitis. Here there is generally a circum- 
scribed globular or flattened globular tumor, usually immovable, which, 
at first at least, is extremely tender. It indicates a fixed mass of 
feces in the cecum or an inflammatory deposit upon the serous side 
of the cecum, or both. In inflammatory cases there remains for a 
long time, or even permanently after recovery, a dense spot (a scar 
from shrunken inflammatory new formation in the peritoneum). In 
inflammation of the vermiform appendix we can seldom affirm that 
there is a tumor. 

Palpation of the peritoneum through the vagina in order to discover 
whether there are tumors, exudations in Douglas's space and anywhere 
in the neighborhood of the uterus, especially the different forms of 
peritonitis, belongs to gynecology. 

Measuring the Circumference of the Abdomen. — It is not necessary 
to measure the circumference of the abdomen for establishing a diag- 
nosis, but yet it is valuable for the purpose of observing the course of 
an abdominal affection, and particularly for ascertaining the increase 
and diminution of fluid exudations. It is generally sufficient to meas- 
ure the abdominal circumference across the navel and the lower lumbar 
vertebrae. It is better also to measure the distance between the xiphoid 
process and the symphysis pubis. 

Percussion gives valuable information regarding the peritoneum as 



284 SPECIAL DIAGNOSIS. 

to whether there is fluid effusion in the peritoneal cavity, its location 
and nature. By percussing with some force at what we suppose to be 
the boundary-line we can easily determine the boundary between the 
dulness of fluid and the tympanitic resonance of the intestine, but we 
can never distinguish it from that of those organs that do not contain 
air, as the liver, spleen, etc. The superior surface of a freely-movable 
effusion is always horizontal, and hence its upper boundary-line must 
correspond to a section of a horizontal plane drawn through the abdo- 
men in whatever position the patient may assume. Whenever the 
patient changes his position, the effusion immediately changes its rela- 
tions to the abdominal cavity.^ Hence the result of percussion changes 
with the position of the body : if the patient lies upon the right side, 
then the portion of the abdomen which is now lowest gives a deadened 
sound, the upper boundary of which is horizontal ; in the left half of the 
cavity there is tympanitic resonance ; if the patient turns upon the left 
side, this is now dull and the right is tympanitic. This is an important 
sign, not only that the fluid is movable, but often that there is fluid 
present. Small effusions, which rarely rise only a little above the 
pelvis, will hence be first recognized by percussing when the patient 
stands upright. If there is then dulness above the symphysis pubis, it 
immediately disappears when the patient lies upon the back. Very 
large effusions may fill the abdomen so full that the intestines, on 
account of a short mesentery, cannot float, and hence cannot come in 
contact with the abdominal wall. Then the strongly-distended abdo- 
men gives a dull sound throughout, and we sometimes notice a change 
of the boundary of dulness only in the position on the side, when the 
upper portion gives a clear sound. 

When \\\^ fluid moves about with difficulty, slowly and incompletely 
changing its location with the change of position of the body, and 
still more if it is entirely immovable, inflammatory exudation with 
gluing or adhesion of the intestines together and to the abdominal 
wall is indicated. If the fluid does not move, it is said to be encysted. 
But not infrequently even inflammatory exudation, at least in the 
beginning of its effusion, is freely movable. 

According to F. Miiller, 200 c.c. of ascitic fluid can be demonstrated 
with certainty in children, while with 150 c.c. there is uncertainty, and 
100 c.c. cannot be recognized at all. In adults only 2000 c.c. give dis- 
tinct dulness, which changes with change of position, whilst with lOOO 
c.c. of liquid the result is doubtful. 

Percussion may be an important aid in recognizing meteorismus 
peritonei, in so far that in many cases, if adhesions have not already 
been formed before the occurrence of perforation, it gives a perfectly 
uniform tympanitic or, if the tension is great, a non-tympanitic, sound 
over the whole abdomen, also over the region of the liver and spleen, 
and, besides, on account of the diaphragm being arched greatly, as 
far as the fifth, or even the fourth, rib. Not infrequently in this way 
we obtain Heubner's rod-pleximeter phenomenon [see page 117]. 

Sjibphrenic peritonitis, pyopneumothorax subphrenicus (Leyden), 
siihphrenic abscess. We understand by this an ichorous-purulent, 
sacculated peritonitis below the diaphragm. From paralysis the dia- 
1 See above, under Inspection. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 285 

phragm is pushed very high into the thorax, causing a marked retrac- 
tion or compression of the lung of that side. That half of the thorax 
is broadened, and by the presence of pus and gas in the cavity one is 
apt to mistake the condition for pyopneumothorax. Peritonitis of this 
character usually begins at the stomach as an ulcer, or at the intestine, 
especially at the vermiform appendix and cecum. In making a dif- 
ferential" diagnosis we observe whether, in the status prccsens or in the 
previous development, there were indications of disease of the lungs 
or, on the other hand, of the abdomen, and also whether the lung of 
the diseased side still performs the motions of respiration. During 
puncture it has frequently been found that during inspiration the press- 
ure in a subphrenic cavity rises, while it falls, of course, in a pleural 
cavity. This can be recognized by the varying rapidity of discharge 
from the aperture made by the needle or by introducing a manometer 
into the cavity. 

The presence of air which has escaped into the peritoneal cavity is 
shown in many cases by the clem', metallic ringing, intestinal sonnd m 
the upper part of the abdominal cavity, sometimes even a metallic, 
transmitted breathing sound which it yields to auscidtation. More- 
over, with the inflammatory deposits upon the reduplications of the 
peritoneum, especially over the liver and spleen, there occurs syn- 
chronously with breathing a peritoneal friction-sound exactly corre- 
sponding to the pleuritic friction-sound. It is very rarely produced by 
peristalsis over the intestines. If the friction-sound is pronounced, it 
can also be felt. 

When it is advisable, as a therapeutic measure, to draw off fluid 
from the peritoneal cavity by puncture, it may be of diagnostic value 
in two ways : 

1. It is then possible to examine the organs in the abdominal cavity 
which previously were concealed by the ascites. Not only does the 
fluid prevent the examination of the organs more or less completely 
covered by it, but the folds of the intestine floating upon it also do so, 
in that they crowd in between certain parts, especially the liver and 
spleen and the anterior abdominal wall. When the abdomen has 
been emptied, its wall, which before was tensely stretched, is very lax, 
and this renders the examination extremely easy. Hence we can 
now usually very easily discover the diseases which caused the effusion 
{cirrhosis of the liver, tumors, which press upon the portal vein, 
cancer of the stomach, ovarian tumor, etc.), or certain results of peri- 
tonitis (bands of scar-tissue which compress the intestine, swollen 
mesentery, etc.). 

2. The fluid that has been drawn off can be examined. It is as 
important to do this as to examine pleural fluid.^ 

The ordinary hypodermatic syringe, having a thinner and larger 
cannula, holding i gram — not the larger one recommended for punct- 
uring the pleura — is to be employed for puncturing the abdomen. 
The place of puncture, the syringe, and cannula are to be carefully 
disinfected before the operation. 

In selecting a place to puncture it is necessary to be careful to 
avoid the stomach and intestines, particularly when they are not 

1 Which see, p. 136,^. 



286 SPECIAL DIAGNOSIS. 

adherent to the abdominal wall. It is true that experience teaches 
that even in puncturing a free coil of intestine there is scarcely any 
risk, but still precaution cannot do any harm. An exploratory punct- 
ure is principally required where the question concerns the distinction 
of soHd tumors from those containing Hquid or from capsulated liquid 
exudates, or where we wish to learn something of the nature of a 
fluid accumulation. In all such cases we have to do with places that 
are dull on percussion, therefore where, a priori, the danger of punctur- 
ing the intestines is not great. Nevertheless, a puncture of the intes- 
tine may easily be made, even where superficial and deep percussion 
has given a dull sound. Therefore, in general, it is more desirable to 
refrain from puncture in the abdominal than in the pleural cavity. 

Frequently the principal interest one has in an exploratory punct- 
ure is that we wish to make certain about the possible presence of 
pus ; and pus enclosed in indurations generally causes the greatest 
difficulty. 

The most frequent case of this kind is to determine a perityphlitic 
abscess. Here there is usually a moderately thick induration, and to 
explore it is really a puncture in the dark. A puncture of the intestine 
in such a case will scarcely have very critical consequences ; but it is 
of more moment to have opened into the free abdominal cavity a road 
for the pus through a thin spot of fibrous adhesion. Thus it has hap- 
pened that the exploratory puncture has not revealed an actual abscess, 
or it may show pus, but not clearly indicate its relation to the appendix 
and cecum. For this reason some do not employ exploratory punct- 
ure here. At all events, we advise always to make it with a fine 
cannula only. 

As for the examination of the exudate which has been withdrawn, 
it is in all respects the same as that of the pleural fluids.^ Besides 
strepto- and staphylococci as exciters of acute peritonitis, there are also 
to be considered, above all, the bacterium coH commune. In chronic 
peritonitis it is of supreme interest to decide whether it may not be 
tuberculous in its nature. Microscopical examination of the exudate 
and of sedimented or sterile filtrated exudate has almost no value at 
all, while culture or vaccination also has scarcely any. Usually nothing 
but an exploratory laparotomy, removing a small piece of induration, 
and vaccinating a guinea-pig, settles the question whether there is tuber- 
culosis or not. However, this question is often decided indirectly — i. e. 
by the presence of other tuberculous diseases, as pulmonary, pleural, 
glandular, or genital tuberculosis. 

Chylous ascites has been observed in some cases of compression of 
the thoracic duct ; the ascitic fluid is, to a varying extent, milk-like in 
appearance. It contains molecules of fat and a ferment that forms 
sugar. 

EXAMINATION OF THE LIVER. 

Anatomy. — The liver, covered by the peritoneum, lies close to the 
diaphragm — within its arch — and is held in place by the suspensory 
ligament and by the intra-abdominal pressure exerted upon its lower 
surface. About three-fourths of it is in the right side of the body, and 

^ Compare p. 136,^. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 



287 



one-fourth in the left. With reference to its superficial topography, a 
larger portion of it belongs to the right hypochondrium, extending 
into the epigastrium, with a small portion into the left hypochondrium. 
Usually it does not extend so far to the left as the apex of the heart. 




Fig. 104. — Location of the thoracic contents, of the stomach, and of the liver, from in 

front (Weil-Luschka). 

The unbroken hatched lines represent the portions of the heart and liver that are in contact with the 
thoracic wall. The portions of these organs that are not in parietal contact and are covered by the lungs 

are represented by the light hatching: ef{ ), border of the right lung ; g h ( ), border of the left lung; 

a b, and c d i^. . . .), boundary of the complementary pleural sinus ; i, boundary between the upper and middle 
lobes of the right lung; /?;, boundary between the middle and lower lobes ; /, boundary between the upper and 
lower lobes of the left lung; %v, stomach (greater curvature). 



Above, the lungs and heart glide over it, and it ghdes over the stomach 
(see Fig. 104). 

The extent to which its surface is in contact with the thoracic wall 
is determined by the relation of its upper surface to the diaphragm. 
Hence during expiration it rises in the right half of the body as high as 
the fourth intercostal space, and with its extreme left end to the fifth 
rib. The lower border, in the scapular and middle axillary line, stands 
about at the eleventh rib in the mammillary line, just at the border of 
the ribs, then proceeds obliquely upward toward the left, through the 
epigastrium, under the left border of the ribs, and almost to the apex 
of the heart. In the middle line, it stands about midway between the 
xiphoid process and the umbilicus. The gall-bladder lies just where 
the lower border of the liver passes under the right border of the ribs, 
hence close within the right mammillary line. 

The organs that border upon the liver are the lungs, the heart, and 
the diaphragm above, and the right kidney, colon, and stomach below. 
That portion of its upper convex surface which is not covered by the 
lungs or heart is parietal. This parietal portion is very small behind. 



288 



SPECIAL DIAGNOSIS. 



As it comes forward it is much broader, and is, for the most part, 
covered by the chest-wall, except in the epigastrium, where it is free 
from its bony covering. 

With children the liver is proportionately larger in all dimensions, 
so that its lower border is in the axillary line below the border of the 
ribs. 

Normally, the liver, strictly speaking, only moves in connection 
with the diaphragm. 

Inspection of the I^iver. — This is made with the body in the 
dorsal position, moderately elevated. 

In the healthy condition, in adults, absolutely nothing can be made 
out. The right and left hypochondriac regions are exactly alike. In 
small children we can sometimes notice a moderate projection of the 
right hypochondrium. 

Projection of tlic rigJit liypochondidinn, or also of the epigastrium and 
the region below the right border of the ribs, indicates enlargement of 
the liver. This must be pretty well marked in order to be noticed in 
this way. Where the thorax is very stiff the ribs do not usually pro- 
ject ; but when the ribs are very flexible (children, young females), 
where it can relatively easily take place, the projection of the abdominal 
wall is plainer if the abdomen is a little full and "the covering thin. 




Fig. 105.- 



-Location of the lungs, liver, spleen, and 
Luschka). 



of the kidneys, from behind (VVeil- 



The liver and spleen are represented by the same kind of hatching as in Fig. 87 : a 3 ( ), lower 

border of the lungs; c d {. . . .), complementary space; z (----), border of the liver; eK. . . .), bound- 
ary between the upper and lower lobes of the lungs ; g; boundary between the upper and middle lobes of the 
right lung. 



If the projection is entirely of the portion of the abdomen below the 
border of the ribs, it points more to a displacement of the liver down- 



I 



EXAMhWATION OF THE DIGESTIVE APPARATUS. 289 

ward. There may be very marked distention when an enlarged Hver 
is so displaced. 

It is very rare to see or to feel tlie lower border of the liver. But 
it may be if, on account of enlargement or displacement, or both, it is 
located low down^ and if the abdominal wall is thin. We can then also 
observe how the border of the hver moves downward with the motion 
of the diaphragm in deep inspiration. For observing this, the light 
must come from the head of the bed. 

When the wall is very thin titnwrs on the surface of the liver in con- 
tact with the abdominal wall or on the lower surface of the border, and 
also a distended gall-bladder, can be seen. With deep breathing they 
follow the motions of the diaphragm, and they transmit the motions to 
tumors of the stomach or omentum, which may be adherent to them, 
or, like them, visible. 

Finally, arterial or venous liver-pulse may be visible, especially the 
latter, which always accompanies enlargement of the liver.^ 

Enlargement of the liver may be dependent upon different diseases 
of this organ. In engorgement of the liver, especially in mitral defects 
and in emphysema, in fatty or amyloid liver, or when it is due to 
obstruction of the gall-bladder, and in diffuse hepatitis, in certain acute 
infectious diseases, the enlargement of the liver is tolerably uniform, its 
form being retained. It manifests itself by its lower border moving 
down into the abdomen, but, on the other hand, the diaphragm is 
pressed upward only when the liver is very greatly enlarged or when 
the general abdominal pressure is increased (especially in ascites). The 
liver is irregularly enlarged in carcinoma, echinococcus, generally in 
syphihs, and in abscess. To what extent it is noticeable depends upon 
the location of the swelHng, whether anterior, inferior, or superior, with 
displacement of the diaphragm. 

Downward displacement (or dislocation) of the liver occurs generally 
with depression of the diaphragm, with severe emphysema, with pleurisy 
or pneumothorax of the right side. Left-sided pleurisy or pneumo- 
thorax, pericarditis, though generally only to a slight degree, press the 
point of the left lobe of the liver downward, and thus the lower border 
of the liver in the epigastrium is horizontal. Moreover, under some 
circumstances the liver is pressed downward by subphrenic abscess,^ 
which at the same time pushes up the diaphragm. Lastly, here belongs 
the "wandering" liver, due to relaxation of the suspensory ligament 
(occurring in women who have borne children). It is only in the two 
conditions last named that it is not in contact with the diaphragm. 

It is to be observed that the lower border of the liver moves down- 
ward, not only when it is enlarged, but also when it is displaced. 
These two conditions will be distinguished chiefly by palpation and 
percussion and the consideration of the accompanying conditions of 
the organs in the chest and abdomen. 

Displacement of the liver upward can, of course, only take place 
when the diaphragm is higher than normal, as in retraction of the 
lungs, pressure from below, inflammatory or neurotic paralysis of the 
diaphragm. 

Palpation of the I^iver. — In every relation this is the most 

1 See below. 2 ggg pp_ 221 and 227. ^ See above. 

19 



290 SPECIAL DIAGNOSIS. 

important and certain method of examining this organ, and hence 
must be most diligently practised by the beginner. It is best to have 
the patient in the dorsal position and the abdominal wall as relaxed as 
possible. We first seize, with the warm hands, the whole abdominal 
sac, have the patient open the mouth and breathe quietly. Drawing 
up the limbs is of little aid and disturbs the examination. We very 
frequently make use of deep breathing, because in this way the parts 
hidden under the ribs move lower down, and the border or any small 
unevenness, etc. can be felt more distinctly as it moves against the 
examining fingers ; and, lastly, because the liver can be distinguished 
from other organs (kidney, colon, omentum, often stomach, abdominal 
wall) by its motions during deep breathing. By striking palpation we 
understand a brusque stroke with the tips of the fingers. We employ 
it in meteorism and ascites in order to push aside for the moment a 
layer of intestine lying over the liver or fluid, and thus be able to reach 
the liver with the tips of the fingers.^ 

Noi'inally, in the adult, with the ordinary thickness of abdominal 
wall, we can feel scarcely anything of the liver. If there is a thin, lax 
wall (especially in women), we not infrequently feel the edge of the 
liver in the mammillary line at the border of the ribs, seldom also in 
the epigastrium, particularly if it is pressed down in deep inspiration. 
In children it is often very distinct. 

For example, we take a condition bordering on the normal, the 
so-called constricted liver, a disease almost without significance. It 
occurs in women who have laced th^emselves very tightly for a long 
time. Corresponding to the anatomical condition of the liver we can 
feel a tongue-like prolongation of the right lobe, which prolongation is 
separated from the mass of the liver by a constricting furrow close 
under the border of the ribs. Sometimes the constricted hver is sensi- 
tive on pressure. 

In ascertaining the pathological conditions of the liver by palpation 
a series of points of view come under consideration : 

1. Tenderness. There is no tenderness with the fatty, amyloid, 
cirrhotic liver, with echinococcus (if there is no formation of pus), 
nor engorged liver (infrequent) if it has been for a long time uni- 
formly engorged : the syphilitic liver is usually not tender, but some- 
times it is so. Generally, in the beginning of cirrhosis the liver is 
sensitive, also in biliary engorgement. According to the extent to 
which the peritoneum is involved, carcinoma of the liver may be 
entirely without tenderness, or it may be very sensitive ; also, when 
engorgement of the liver has rapidly developed, it may be very tender. 
When an abscess of the liver is parietal, possibly involving the peri- 
toneum, there is a circumscribed area of great tenderness ; with deep- 
seated abscess there is no pain. Tenderness of the liver may, besides, 
be caused by chronic (often tubercular) peritonitis, without there being 
any trouble with the liver itself 

2. The size and form. Depression of the lower border, without 
change in form, indicates uniform enlargement, but possibly also dis- 
placement. Unless there is considerable enlargement it is often 

1 See, moreover, what is said on page 285 regarding palpation of the abdomen after 
puncture. 



EXAMIXATIOX OF THE DIGESTIVE APPARATUS. 29 1 

difficult to distinguish between these two conditions. If there is 
simultaneously tenderness and hardness/ or if there are conditions of 
other organs which make enlargement of the liver probable, as valvular 
disease of the heart with engorgement, one of the diseases causing an 
amyloid condition, etc., then we are very seldom wrong in the supposi- 
tion that there is an enlargement. On the other hand, displacement 
may be made more probable, for example, by the existence of plcuritis 
exiidat. dextra, etc.^ There also may be at the same time enlargement 
and downward displacement. But it must be remembered that when 
a liver is markedly displaced downward the impression is easily made 
that it is also enlarged, because by traction about its transverse axis it 
becomes parietal to a larger extent. 

When a downward-displaced liver is distinctly movable by pressure 
with the finger, in such a way that in the dorsal position it can be 
brought back to its normal position, then we have a " wandering " 
liver. . 

The /(?;'/;/ of the liver is recognized with varying distinctness, accord- 
ing to the increased extent to which it lies against the abdominal wall 
when it is enlarged. It has already been mentioned under what 
conditions the liver retains its form. Tumors of all kinds (especially 
carcinoma, gummata, echinococcus) and scars (syphilis) change its 
form. Whole portions of the parenchyma of the Hver may often, not 
always, be marked off by the scars of syphihs if they are very deep — 
" lobulated liver." 

3. Again, the surface of the liver can be judged by the portion of 
the upper surface or the lower border which is accessible to palpation, 
and we can do this best by moving the finger-tips with the abdominal 
w^all back and forth over the liver. In individual cases it is possible to 
feel a portion of the lower surface. In engorgement of the liver, in fatty 
Hver, in amyloid liver, in a portion of the first stage of cirrhosis, and 
in the so-called hypertrophic liver, the surface will be found to be 
smooth ; also, in echinococcus, carcinoma, and syphilis of the Hver if 
we palpate a portion entirely free from tumor or scars. Small inequali- 
ties, generally to a certain extent uniform over the whole palpable 
portions of the surface, sometimes so fine that if the abdominal wall is 
thick it is difficult to feel them, are the characteristic signs of ordinary 
cirrhosis of the liver (interstitial hepatitis, granulated liver) toward the 
end of the first stage and into the second. Here, for two reasons, it is 
usually very difficult to reach the liver with the fingers : first, because 
in the second stage it is smaller, and hence is to a less extent parietal ; 
and second, because the disease is commonly associated with ascites. 
For this reason what has been said regarding " stroking palpation " and 
examination after puncture applies especially here. It is further to be 
remarked that the surface of the liver in chronic, and especially in 
tubercidar, peritonitis may feel tuberculated in consequence of inflam- 
matory growths upon the serous coat, and this without there being any 
cirrhosis (although not infrequently this exists at the same time). 
Large rough tumors, from the size of a cherry to that of an apple, 
often mingled with small knots, are the usual appearances with carci- 
noma of the liver. We can sometimes recognize upon the top of these 

^ See below. ^ See above. 



292 SPECIAL DIAGNOSIS. 

carcinomatous knots a depression, the cancer navel, but they are of 
neither positive nor negative diagnostic weight. More smooth, flat 
projections, especially if, besides, we can feel scar-like depressions, indi- 
cate the presence of syphilitic gummata. EcJiinococcus causes smooth 
tumors which, according to their location, are flat or elevated, or they 
may even stand out prominently from the surface of the liver ; abscess 
of the liver also causes smooth prominences of different sizes and 
elevations. 

4. The consistence of the liver is uniformly, and generally markedly, 
increased in amyloid disease, engorged liver, and in cirrhosis. Car- 
cinoma manifests itself, as elsewhere, usually by great density. 
Abscess of the liver and echinococcus bladders may distinctly fluctu- 
ate ; the latter often, if tightly full, feel dense as well as elastic, and 
we can sometimes recognize by quick, short strokes of the opposing 
hands a peculiar whizzing — the liydatid thrill. 

In many cases exploratory puncture will be indicated, as, for instance, 
in order to recognize or exclude echinococcus or abscess. (Regarding 
the condition when there is echinococcus, particularly of the effects, see 
Tumors of the Abdomen.) Moreover, it is necessary to compare the 
results of palpation, in the broad sense of the word, with the accom- 
panying appearances of other organs which belong to the individual 
diseases of the liver. These may have a casual relation to one another 
(constitutional syphilis, primary cancer of the stomach, etc.), or they 
may be results (ascites in cirrhosis of the liver or pressure from tumors, 
scars of the portal vein, rigors in abscess of the liver, etc.). 

The gall-bladder. If this is normal, it is only in cases of extreme 
emaciation that it can occasionally be felt. This is much sooner pos- 
sible when it is abnormally full of fluid, as in biliary engorgements, 
hydrops vesicce fellece, suppuration, or when it is distended with gall- 
stones. In biliary engorgement and catarrhal icterus it is possible to 
diminish the gall-bladder by carefully compressing it and expelling the 
contents into the ductus choledochus and the duodenum. When 
there are gall-stones, if the abdominal wall is thin we sometimes get 
the distinct impression of a sac filled with angular stones rubbing 
against one another. A dense, rough tumor indicates carcinoma of 
the gall-bladder. 

Percussion of the I<iver. — Wherever the liver is in contact with 
the thoracic or abdominal wall we, of course, have dullness, and this 
is an absolutely deadened sound where the liver receives the whole of 
the percussion-stroke, and the stroke is not permitted to reach to an 
underlying air-containing organ, as the intestine or stomach. Rela- 
tive dulness, with tympanitic associated sound, occurs when a thin 
layer of liver lies over the stomach or intestine, as is the case in the 
neighborhood of the lower border of the liver. To a certain extent it 
depends upon the strength of the percussion-stroke whether we have a 
relative or an absolutely deadened sound : ^ the weaker the stroke the 
sooner do we have absolute dulness. The varying thickness of the 
covering of the liver is confusing, consisting partly of ribs and partly 
of abdominal wall. Still more confusing for exact examination is it 
that the border of the arch of the ribs, at the most important point in 

^ See p. 94. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 293 

the mammillary line, normally exactly corresponds with the lower border 
of the liver. The difference in sound which is caused by this change 
in the covering alone obscures the exact examination of the liver at 
this point. 

The limits of the liver, so far as they are determined by percussioit, 
are ascertained by gentle percussion at the right lower border of the 
lung by the transition from the clear lung-sound (or relative liver- 
dulness) to the absolutely deadened sound. Thus, the upper boundary 




Fig. 106. — Percussion boundary of the liver in front (Weil). 
g k, the upper limits of the lungs ; e/, the lower limits of the lungs ; d d, the boundary between the lung 
and heart at the incisura cardiaca. The darkly-hatched surface represents the portions of the heart and liver 
that are in contact with the chest-wall; the light hatching, the so-called relative heart- and liver-deadness ; 
m, spleen-deadness ; n, the average position of the lower border of the stomach. 

of the parietal part of the liver is easily found, with the exception of a 
small portion where the liver lies against the heart (see Fig. 106). Here 
we cannot determine the boundary by percussion, because the heart- 
dulness and liver-dulness cannot be distinguished. The lower border 
of the liver near the spine cannot be pointed out, because it joins the 
kidney (see Fig. 105), but everywhere else its sound could be very easily 
distinguished from the tympanitic sound of the stomach and intestine if 
its anterior part were not too sharp ; that is, if the liver were not here 
too thin. For this reason, even with the most gentle percussion in the 
epigastric region, it is usually found too high. Often no distinct liver- 
dulness can be perceived in any portion of the epigastrium. Moreover, 
we must guard against being deceived by the dulness of one of the 
beUies of the rectus abdominis (lax abdominal wall). 

The relative liver-dulness lying above the absolute does not corre- 
spond to the anatomical size of the liver, which lies much farther back 
than this, as is shown by a comparison of the anatomical figure (see 



294 SPECIAL DIAGNOSIS. 

Fig. 104) with the boundary as determined by percussion. This is 
because the lung becomes thinner at its lower border ; moreover, it is 
only anteriorly and at the side that it is always distinctly present. It 
usually fails between the scapular Hne and the spine, owing to the thick 
wall and the diminished sharpness of the edge of the lung. 

Mode of Procedure. — We percuss strongly or lightly down a known 
vertical line on the thorax for determining the beginning of relative 
liver-dulness, and thus fix the lung-hver boundary ; that is, the transi- 
tion from the relative to the absolute liver-deadness. Then we percuss 
downward, through the extent of liver-dulness, until by the gentlest 
percussion we get the entirely pure tympanitic sound. From this point 
we go again upward till we get the first indication of relative dulness. 
We determine the exact boundary-lines by exclusion.^ 

The average boundary -lines of the liver, as determined by percussion, 
are about as follows : 

The upper, the lung-liver boundary : Middle Hne, the base of the ensi- 
form cartilage ; mammillary hne, the sixth rib ; middle axillary line, the 
eighth rib ; scapular line, the tenth rib. 

The heart-liver boundary cannot be determined by percussion, but 
it lies near the apex-beat. 

The lower, the liver-stomach (intestine) boundary : Left of the mid- 
dle line, toward the halfmoon-shaped space, ascending obliquely to 
about the sixth rib in the parasternal hne ; middle hne, not lower — often 
higher — than midway between the xiphoid process and the umbilicus ; 
mammillary line, at the bend of the ribs ; middle axillary line, the tenth 
rib ; scapular line, the eleventh rib. 

But from these there is frequently a considerable departure, even 
normally. Throughout, the lower boundary has been found much 
higher, this being caused by a fold of intestine lying over the liver and 
thus diminishing the extent to which it is parietal. This is particularly 
the case with the ugly but not pathological form of the thorax where 
it is short and its lower aperture is quite wide ; also in persons who 
have a full abdomen. In this way the liver-dulness may sometimes be 
entirely wanting : at the upper boundary of the halfmoon-shaped space 
we pass, in percussing, from lung-sound into tympanitic resonance. 

Extreme elevation of the liver-dulness, although very variable 
within normal limits, is not at all applicable in diagnosis. 

Mobility of the Boundaries of the Liver. — In deep breathing there is 
a more marked active displacement of the upper boundary (correspond- 
ing to the respiratory excursion of the border of the lung) than of the 
lower, which displacement is the expression of the movement of the 
dome of the diaphragm. As regards passive movements we only 
notice that in the left-side position both boundaries move downward 
— the upper distinctly so f the lower, very little. 

Pathological Relations. — i. The upper boundary of dulness is 
found higher. The cause of this can first of all be found in the pleural 
cavity : pleural exudation, tumors of the pleura, of the lungs, pneu- 
monia ; or in the chest-wall : tumors, peripleuritis. Then, of course, it 
is not possible to distinguish the dulness of what lies above the liver 
from that of the liver itself, since two media that on percussion give 

^ See p. 102,/. 2 gge Lungs. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 295 

dulness cannot be distinguished from one another. If there is exuda- 
tive pleuritis upon the right side, the diaphragm is deeper and the hver 
moves down, causing its lower boundary of duhiess to be lower, and 
thus in this disease there may be an extensive dulness, reaching from 
high in the thorax to far below the border of the ribs — dulness of the 
exudation plus liver-dulness. 

If the conditions just named are excluded, then we may have — 

{a) Displacement of the liver upward, with high position of the dia- 
phragm. Then, at the same time, the lower border of the liver is 
higher, and indeed the latter is displaced upward farther than the 
former, because the liver as it moves upward in a sense turns on its 
axis ; that is, the lower border turns up, so that it is to a less extent 
parietal — the square position of Frerichs. (For the conditions which 
displace the liver, see above.) 

{U) A tumor of the convexity of the liver as a new formation, an 
abscess, echinococcus, when the upper boundary of dulness pursues an 
irregular course, according to the form of the tumor, or a subphrenic 
abscess. In these cases, the liver is usually displaced downward, often 
very markedly so ; hence, the lower boundary of the liver at the same 
time stands deeper. 

{c) A general enlargement of the liver. This causes a high position 
of the upper boundary only when the liver is very large. Here also 
the lower boundary of dulness is considerably lower. It is often very 
difficult to distinguish, and then only by inspection (projection) and 
palpation of the surface and consistence of the liver and other evidences 
of disease referred to under {fi). 

2. The upper boundary of dulness is found lower. This occurs — 
id) With a simultaneous normal position of the lower boundary in 

slight substantive and in vicarious emphysema. Although in this case 
the lung moves down into the complementary space, and thus covers 
the liver somewhat more than is normal, yet the dome of the diaphragm 
does not become deeper. 

[b) With simultaneous downward displacement of the lower bound- 
ary : low position of the diaphragm with the liver ; marked emphy- 
sema with low position of the diaphragm ; pneumothorax. We can have 
the same percussion-results with considerable emphysema and enlarge- 
ment of the liver. Finally, there may be low position of both boundaries 
resulting from the low position and enlargement of the liver. This is 
a frequent occurrence in severe emphysema, because of the existing 
engorgement of the liver. 

When the liver is displaced downward it easily gives the impres- 
sion of being enlarged, without such being the fact, because it is often 
parietal for a larger area than is normal. Also, for this reason the 
liver-dulness is higher than it is normally on the average ; especially 
in pneumothorax is it often distinct. 

3. The behavior of the lower boundary when the upper is displaced 
has in general been already mentioned. It remains to be noticed that, 
when the liver is pushed down by a thoracic affection on the right side 
[pleurisy, pneumothorax), it stands obHquely ; that is, the right lobe 
is deeper than the left, hence the depressed lower boundary of dulness 
stands steeper than normal, sloping from the right toward the left. On 



296 SPECIAL DIAGNOSIS. 

the other hand, when we have a pleurisy or pneumothorax upon the 
left side or marked pericarditis exudativa, since the left end of the 
liver {lob. sinistra) is then alone pressed down, the lower line of dulness 
is found more horizontal. 

With a normal upper border the lower boundary stands deep and 
reaches farther into the halfmoon-shaped space when the liver is en- 
larged ; on the other hand, it is higher than normal, under some cir- 
cumstances even until the liver-dulness completely disappears in the 
following conditions : {a) If the liver is smaller, as in cirrhosis, acute 
yellow atropJiy, here occurring rapidly. (B) As happens much more 
frequently than id), if the liver, though perfectly sound, is less 
parietal than normal, or is not at all so, as in those who are on the 
whole well — in meteorism, ascites, entrance of air into the peritoneum. 
In this way even an enlarged liver may elude examination. In yet 
two other rare cases is the liver-dulness entirely wanting — in situs 
inversus visceruvi and in cases of " wandering liver." With the latter 
sometimes a portion of the upper surface of the liver will be found in 
contact with the abdominal wall farther down. 

Apparent low position of the lower border occurs when there is an 
airless mass below the liver, as with a full colon or a large tumor of 
the colon, of the omentum, or of the stomach, although these are rare. 

The/<?r;;2 of the lower border departs from the normal when there 
is unequal enlargement of the liver ; ^ also sometimes in marked en- 
largement of the gall-bladder, seldom determined by percussion.^ 

4. Relative liver-dulness is diagnostically of little interest. It is 
relatively high if the diaphragm rises steeply upward and inward from 
the thoracic wall, and very low if the diaphragm goes off perpendicu- 
larly from the thoracic wall, as in severe emphysema, but especially in 
pneumotJwrax. 

All in all, percussion of the liver, when rightly performed and cor- 
rectly interpreted, is of very great value. But where palpation can be 
employed, as is usually the case whenever the inferior border of the 
liver is lower than normal, it must yield to the latter method of exam- 
ination, which is more anatomical and hence more exact. If the 
border of the liver can be felt, then we note its course upon the body 
by the results of palpation and not of percussion, and proceed with 
the diagnosis in accordance with this position. 

EXAMINATION OF THE SPLEEN. 
Anatomy. — The spleen, a long, generally almost oval, organ, lies 
in the left hypochondrium, between the ninth and eleventh ribs, in 
such a way that its long diameter in the dorsal position of the body 
lies almost exactly behind and parallel to the tenth rib. Its posterior 
end lies about 2 cm. from the tenth dorsal vertebra ; its anterior end, 
normally, scarcely reaches to a line drawn from the tip of the eleventh 
rib to the left sterno-clavicular articulation (linea costo-articularis) ; at 
any rate, does not pass beyond it. The upper (anterior-upper)^ of the 
two borders of the spleen exhibits one or two notches. 

^ See above. ^ For the different kinds of enlargement, see under Palpation. 

^ In what follows I designate the two borders of the spleen as " upper " and " lower," 
because from the topographical standpoint that always seems to me the most natural. We 



EXAMINATION OF THE DIGESTIVE APPARATUS. 



297 



even 
result. A 



The spleen lies close to the under surface of the diaphragm, in the 
periphery of that portion which rises sharply upward, and toward its 
inner lower end it covers a small portion of the upper part of the left 
kidney, also the colon and stomach. Topographically, with reference 
to the thorax, its location is as follows : Its upper third, during moderate 
respiration, is covered by the lung. The lower two-thirds are in con- 
tact with the thoracic wall, but it changes its relation somewhat with 
the position of the body by reason of the passive mobility of the border 
of the lung.^ Its upper border follows the ninth rib, forms the outer 
boundary of the " halfmoon-shaped space," and stands at a sharp angle 
with the lower border of the lung (see Fig. 107), called the spleen-lung 
angle, whose apex in the upright position is about at the posterior 
axillary line, but when in the right-side position, in consequence of the 
movement downward of the lower border of the lung it moves some- 
what forward, even as far as the anterior axillary line. Its lower border 
follows the eleventh rib, and for the most part bounds the left kidney. 

The spleen is in parietal contact only in its lower two-thirds, but it 
cannot be reached by the finger, except sometimes by turning the 
abdominal wall under the border of the ribs. 

Inspection of the Spleen. — In the normal condition, and 
when greatly enlarged, inspection of the spleen gives no 
very considerable enlargement causes 
a projection of the left hypochondrium 
and of the abdominal region obliquely 
inward and downward from it. When 
the abdominal wall is thin the border 
of the enlarged organ or a circum- 
scribed swelling on its parietal surface 
may be seen. Then, if the upper end 
of the spleen has not left its place 
close to the diaphragm,^ it usually 
plainly descends with deep inspiration. 

Palpation of the Spleen. — Pal- 
pation is very much the most import- 
ant method of examination, because 
its results are much more reliable than 
is the case with percussion. Ordinarily, 
in order to employ palpation it is nec- 
essary for the patient to assume what 
is called the diagonal position on the 
right side — that is to say, a position 
midway between the dorsal and the 
right-side position — for the reason 
that percussion can be practised 
very much better in this position, 
and because the unity of the position 
is useful for comparing the results of 
the two methods of examination. When the patient is very sick it 




Fig. 107. — Location of the spleen (Weil- 
Luschka). 

d, lower border of lung; eg, comple- 
mentary space ; ef, greater curvature. The 
parietal portion of the spleen, continuous 
hatched lines ; that covered by the lung by 
broken hatched lines. 



IS 



speak of an upper and a lower border of all the ribs, even of the lower ones, which are 
oblique. I cannot understand why one of the two ends of the spleen should be called the 
"upper" and the other the "anterior," as is done by Weil. ^ See this. ^ See below. 



298 SPECIAL DIAGNOSIS. 

better to palpate in the dorsal position. When the spleen is of very 
considerable size this is also best (then, too, it is preferable for per- 
cussion). If it is difficult to find the spleen, then we try the right-side 
position, because this more fully relaxes the left side of the abdominal 
wall. If we have the patient take several deep inspirations, a slight 
swelling of the spleen can usually be made out by feeling the anterior 
end of the organ close to the border of the ribs, at about the tenth rib,, 
where it comes in contact with the tip of the finger. Without further 
investigation we cannot refer a simple increase of resistance at the edge 
of the ribs to the spleen, but we must seek further to feel its borders. 
The spleen can be felt — 

1. In individual cases in health, when the abdominal wall is very 
lax ; also, sometimes, in persons with deformed chest (kyphoscoliosis). 

2. If it is enlarged. It may be enlarged and yet retain its form. It 
is uniformly enlarged in certain acute infectious diseases, as in typhoid, 
exanthematous, and recurrent fevers ; in scarlet fever, usually in severe 
smallpox ; in malaria, here relatively very large ; in erysipelas, here 
often slightly enlarged ; in sepsis and pyemia ; sometimes in acute 
mihary tuberculosis ; in engorgement of the spleen, especially in 
cirrhosis of the liver ; in occlusion of the portal vein ; in general 
venous engorgement ; in amyloid disease of the spleen ; in leukemia 
(greatest enlargement) and in splenic anemia ; sometimes in infarction 
of the spleen (heart-disease) ; and also in tubercular peritonitis. We 
must here also mention the apparent enlargement of the spleen where 
there are thick peritoneal deposits (perisplenitis). 

It may also be unequally enlarged by new formations, especially by 
carcinoma, and by echinococcus and abscess. 

3. It may be felt if it is displaced, with low position of the diaphragm 
(rare) ; the " wandering " spleen. 

In palpating we take notice of — 

Pain. — Tenderness, probably always from the peritoneum, sometimes 
occurs in acute infectious diseases, in suddenly developed engorgement, 
in infarction of spleen, new formations, and abscesses. There may 
sometimes, in abscesses and infarction, be tenderness to pressure upon 
the ribs in the neighborhood of the spleen. 

Size. — The largest tumors of the spleen, often reaching into the 
right side of the abdomen, occur in leukemia. On the other hand, in 
the acute infectious diseases we have moderate enlargement of the 
spleen which does not come below the border of the ribs. In other 
diseases the splenic tumor varies very much in size. 

Pulsating splenic tumor (systolic pulsation of spleen) has been 
observ^ed now and then in cases of aortic insufficiency. 

Consistence. — As a rule, the consistence increases with the size, and 
is more dense in chronic than in acute cases. Generally, the consistence 
is not a guide in diagnosis. 

Form ; Surface. — It has already been mentioned in what diseases the 
spleen is uniformly, and in what unequally, enlarged. In diseases of 
the first group we can almost always, and in the latter sometimes, feel 
distinctly the notches in the upper border if the spleen projects far 
enough beyond the border of the ribs. In carcinoma the surface shows 
hard, uneven tumors ; in echinococcus they are round, tense, elastic. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 299 

But in leukemia the surface is not always uniform, for it may sometimes 
exhibit flat elevations. 

Mobility. — We have already mentioned the downward movement of 
the spleen with deep inspiration. I have seen cases of very great 
enlargement of spleen where this did not take place, because the spleen 
had pushed the diaphragm high up on the left side ^ and hindered its 
contraction. 

Wandering spleen is characterized by absence of respiratory move- 
ment ; but the spleen is passively movable, and sometimes even shows 
displacement downward with change of posture, a condition which 
occurs only in women. The spleen may wander astonishingly far 
from its place, even into the true pelvis, and it has been found in the 
abdominal cavity entirely free from its attachments ; but usually there 
is only sHght displacement. Tumors of this kind are recognized as 
wandering spleen by their form and by the notches. Often it is at 
the same time enlarged. A spleen displaced by the low position of 
the diaphragm can seldom be felt. (See further, regarding displace- 
ment, under Percussion of the Spleen.) 

Relation of the colon to the spleen : Enlarged and wandering spleen 
lies in front of the colon. We can best prove this by inflating the colon 
with air^ in connection with palpation and percussion. 

Percussion of the Spleen. — Percussion is limited to that portion 
of the spleen which is not covered by the lung (Weil). It is bounded 
above by the lung ; toward the front, superiorly, we have the upper 
border ; inferiorly, the anterior end, and a portion some distance behind 
(inferior border), against the stomach and intestine : farther back, against 
the kidney. But this latter portion cannot be defined, there being dul- 
ness against dulness. 

When we can only percuss with the patient in one position, as with 
very sick patients, we do so in the right diagonal posture. But if we 
wish to be very exact and the patient can bear it, it is best also to per- 
cuss in the upright posture. Let it be repeated thdX palpatio7i generally, 
even though the physician be skilful in percussion, gives a much more 
certain result. But percussion must never be omitted. When the 
spleen is very much enlarged we may examine the patient in the dorsal 
position. The diagonal posture is only required to determine whether, 
and how much, the spleen pushes up the diaphragm. 

In both the diagonal and the upright posture we begin by determin- 
ing the lower border of the left lung. It is normally in the upright posi- 
tion : mammillary line, the sixth rib ; middle axillary line, the eighth rib ; 
scapular line, the tenth rib. In the diagonal position it varies from the 
seventh to the eleventh rib. From here, if we percuss in the vertical 
line, over the border of the lung downward, and, in the diagonal posi- 
tion, about in the anterior or middle axillary line, below the border of 
the lung, we will meet dulness instead of the tympanitic sound of the 
halfmoon-shaped space : spleen-dulness. The place at the border of 
the lung where the dulness is met with is the apex of the spleen-lung 
angle.^ We now percuss vertically downward, through this angle 
beyond the deadened sound, till we come to a tympanitic (intestinal) 
resonance : the boundary-line is the lower border of the spleen. Then 

^ See Percussion, 2 gee p. 280. '^ See Anatomy, p. 297. 



300 



SPECIAL DIAGNOSIS. 



we percuss from the halfmoon-shaped space and from the abdomen 
upon hnes which cross what we suppose to be the area of spleen-dulness, 
and thus ascertain where the tympanitic stomach or intestinal resonance 
changes to duhiess. This marks the hne of the spleen. If we mark 
these points and connect them, we obtain the figure of Ihe parietal por- 
tion of the spleen, which we can complete by determining the lower 




Fig. io8. — Position of the spleen (Weil). 
M, the middle line of the back; A,B, C, the axillary lines; Sc, the scapular lines; abed, spleen; 
abcd,\m\is\id\ rhomboidal form of the spleen; efg, outer boundary of the kidney; Idc, the spleen-lung, 
and dhg, the spleen-kidney angle ; «;«, the lower border of the liver. 



border of the spleen in the posterior axillary line or in a vertical line 
between this and the scapular line. 

In the upright position the conditions are altered in such a way 
that the border of the lung on the left side, and with it the lung-spleen 
boundary, is somewhat higher,^ and hence we find the apex of the lung- 
spleen angle in the middle or posterior axillary Hne. 

As has already been said, the size of the spleen-dulness, with care- 
ful percussion and under favorable conditions,^ corresponds to the 
parietal part of the spleen. From this we must estimate the size of the 
spleen. In measuring it we have only two points of departure : the 
height of the spleen-dulness in the vertical line passing through the 
apex of the spleen-lung angle, and the relation of the anterior end of 
the spleen to the linea costo-ai^ticiilaris. The average in health has 
been found to be (Weil) — 

In the diagonal posture the height of the spleen is 5.5 to 7 cm., the 
anterior end at most reaching to the linea costo-articularis. 

In the upright position the height is 4.5 to 6 cm., the anterior end 
under some circumstances passing a little beyond the linea costo-artic- 

^ See above. ^ See below. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 3OI 

zilaris, the spleen-lung angle more pointed ; that is, the spleen is a little 
more horizontal. 

We are interested in the mobility of the spleen-dulness in deep 
inspiration only so far as it affects the boundary between the spleen 
and lung.^ 

Weil has sufficiently explained why we must forego the determina- 
tion of the portion of the spleen which is covered by the lung. I 
agree entirely with him, and refer to his work upon Topographical 
Percussion. 

In the first place, we percuss tolerably strongly. If in that way we 
obtain no result, we then percuss very lightly. With strong percussion 
we very rarely have resonance over the spleen ; also, with moderately 
strong, only rarely absolute deadness. Also, by gentle percussion, we 
must often be satisfied with a relative dulness associated with tympanitic 
accompaniment. 

Departures from what has been called the " average " in health : 
[^] Very often in health the dulness of the spleen as regards its size 
or intensity is only suggested, so to speak : in such cases it is covered 
by intestine, or the spleen is thin and the intestines near it are dis- 
tended by gas. 

[^] The area of dulness of a normal spleen seems larger, and occasion- 
ally exactly corresponds also in form with a uniformly enlarged organ. 
This occurs when the stomach is overloaded with food, when there are 
fecal masses in the neighboring colon, when there is corpulence (the 
greater omentum loaded with fat), but also sometimes without these 
conditions being present. We must guard against deception as re- 
spects the stomach and intestine by repeated examinations, especially 
with abstinence from food and after free purgation. When there is 
obesity we ought not, on the whole, to draw any conclusion from a 
large area of spleen-dulness. 

But, at any rate, we must never by a single examination diagnos- 
ticate a spleen-tumor from percussion alone. 

Pathological Relations. — As mentioned above, diminution of 
spleen-dulness is often met with in health. In sickness it occurs from 
overlapping of the spleen from above by the lung : this happens with 
emphysema of the lung, when the lung spreads into the comple- 
mentary space ; sinking down of the lower border of the spleen and 
its anterior end is evidence of displacement downward by flattening 
of the diaphragm, but in emphysema this cannot be proved. There 
is always diminution of spleen-dulness (even to complete disappear- 
ance) when it is displaced upward, as in shrinking after pleurisy, 
contraction of the lung, high position of the diaphragm. Here, gen- 
erally, there is no spleen-dulness at all, on account of the intestine 
lying over it. 

Enlargement of Spleen-didness. — If we make out such a condition, 
we ought to call to mind the sources of error mentioned above. We 
should never make the diagnosis of enlarged spleen from a single 
percussion without the support afforded by palpation. We must 
notice whether the enlarged dulness shows the relations of the figure 
of the spleen ; if it does, then it is quite probable that the spleen is 

1 See what has been said regarding active mobility of the border of the lung. 



302 SPECIAL DIAGNOSIS. 

enlarged ; likewise if the examination in the diagonal and the standing 
position shows a similar result, with change of dulness that distinctly 
corresponds with the changed position of the border of the lung and 
the spleen. 

Enlargement of the spleen is to be assumed when the vertical 
measurement of dulness is as much as 9 cm. or more ; also if the area 
of dulness extends considerably beyond the linea costo-articularis ; 
and, lastly, if the dulness is very decided, that is, with moderately 
strong percussion absolute deadness. When there is considerable en- 
largement of the spleen, the area of dulness upward is larger, and 
hence the diaphragm, and with it the border of the lung, moves higher 
in the chest. Moreover, in every upward enlargement of the spleen- 
dulness it is to be remembered that it may be merely apparent, being 
caused by pleuritic exudation, infiltration of the lungs, or pleural tumor. 

When there is a decided enlargement of the spleen, it considerably 
diminishes the halfmoon-shaped space. If there is, simultaneously, 
tumor of spleen and liver, the space may be entirely deadened. 

Auscultation of the Spleen. — In rare cases auscultation enables 
us to recognize peritoneal friction-sounds should there be inflammatory 
deposits upon the serous coat of the spleen and the parietal portion of 
the peritoneum opposite it, if the diaphragm is not paralyzed by the 
peritonitis, or the spleen has not become adherent. Peritoneal friction- 
sound over the spleen (and over the liver) seems to me to have greater 
weight as evidence that the first of the two last-named conditions is 
wanting than as the sign of peritonitis, for the latter usually appears to 
be plainer from other symptoms. It may easily happen that we find it 
difficult to distinguish whether we really have peritoneal rather than 
pleuritic friction-sound. Auscultating with the stethoscope enables us 
to localize the sound more exactly. We must also take into consider- 
ation the whole picture of the disease. 

EXAMINATION OF THE PANCREAS, OMENTUM, RETRO= 
PERITONEAL GLANDS. 

The pancreas is accessible for examination, and even to palpation, 
if it is the seat of new formation, as of carcinoma, especially of the 
captit pancreatis, and hence is larger and harder than normal : we have 
a roundish tumor in the right epigastrium which does not move during 
respiration, about midway between the point of the xiphoid cartilage 
and the umbilicus, hence directly under the border of the liver ; or a 
somewhat longer tumor across the epigastrium. Unless there are char- 
acteristic associated symptoms (compression of the ductus choledochus 
and pancreaticus, biliary engorgement, and change in the character of 
the stools — diabetes mellitus), the diagnosis of tumor of the pancreas 
can scarcely be made from such a tumor, which may also belong to 
the omentum, but especially to the retroperitoneal glands. 

The omentum also is only perceptible when it is thickened by 
inflammation or by new formations or by both. It frequently shrinks up 
to a transverse band, crossing close above the umbilicus if it is the seat 
of tuberculosis, or also in "simple" chronic peritonitis. As regards its 
mobility in respiration, such an omentum may behave differently, de- 



EXAMINATION OF THE DIGESTIVE APPARATUS. 303 

pendent upon its being adherent to the abdominal wall or attached to 
the stomach. Carcinomatous knots in the omentum are best to be 
distinguished from similar deposits in the anterior wall of the stomach 
by examining the latter both when empty and when full or inflated. 
Sometimes it is very difficult to distinguish them from carcinoma of the 
liver, especially if the omentum, from adhesion with the liver, moves 
with each respiration. Echinococcus of the omentum is quite rare. 

Enlargement of the retroperitoneal glands generally occurs in 
secondary carcinoma as firm, immovable bunches which are located in 
the cavity of the abdomen, about on the level with the umbilicus, but 
sometimes they reach even deeper. They may compress the side of the 
inferior vena cava or the iliac vein. These glandular tumors may easily 
be confounded with aneurysm of the aorta, especially if they are round 
tumors and propagate pulsations, and they also may even communicate 
a humming murmur of stenosis from the aorta. 

We must again call attention to the importance of always empty- 
ing the intestines and bladder, and artificially inflating the stomach 
and intestines, in all cases of this character where the diagnosis is 
difficult. 

This is not the place to explain the differential diagnosis of a large 
number of other affections of the abdomen, especially tumors of the 
uterus, ovaries ; also pregnancy. (We refer for these to works upon 
Gynecology and Obstetrics.) 

EXAMINATION OF THE CONTENTS OF THE STOMACH. 

In general we may in two ways obtain the contents of the stomach 
for examination : when the patient vomits, or when, by emptying the 
stomach by means of an esophageal catheter, we remove a portion of 
its contents. The catheter may be introduced for therapeutic purposes 
or only for the purposes of diagnosis. 

The latter way of obtaining some of the contents of the stomach, it 
is readily seen, is the more exact for making a diagnosis, because we 
regulate the time for doing it by the object we have in view. First, 
with reference to the most important problem in the diagnosis of the 
contents of the stomach — namely, the examination of the stomach- 
digestion and the secretion of gastric juice — it is only necessary to 
empty the stomach to obtain the object required. At the same time, it 
is to be remembered that in many cases the examination of vomited 
matters has its particular value, and that occasionally — for instance, in 
cases of poisoning — the fluids employed in rinsing out the stomach are 
to be examined if such rinsing out is therapeutically necessary. 

However, very frequently it is possible to combine the therapeutic 
with the diagnostic emptying of the stomach, as is shown by a com- 
parison of therapeutic indications with those of the diagnosis. We 
cannot here enter more fully into this subject. 

Artificial emptying of the stomach, or removal of some of its contents 
for the purposes of diagnosis, is, as has been said, the only method 
which enables us to form a reliable opinion regarding the gastric 
secretion and the process of digestion, for the reason just given, that 
such an opinion can usually only be formed when the contents of the 



304 SPECIAL DIAGNOSIS. 

Stomach have been obtained in a perfectly unmixed state and at a 
definite time after partaking of a meal. Vomiting can make the 
artificial emptying of the stomach unnecessary only when it occurs at 
exactly the time desired, and when the material vomited does not 
contain bile and not too much mucus.^ 

Liductioii of cnicsis is contraiiidicatcd when there is a tendency to 
hemorrhage, and in poisoning where we have reason to think the 
poisons, as acids and alkalies, have caused erosion of the esophagus or 
stomach. Sounds, even soft ones, are to be employed with the 
greatest caution, and only when the stomach is unquestionably full, if 
there has ever been any hemorrhage of the stomach, and also when 
there is any suspicion of an ulcer of the stomach or of a markedly 
ulcerating carcinoma. It has already been mentioned^ that a suspic- 
ion of aneurysm of the aorta forbids any introduction of the stomach- 
tube. 

The examination of the contents of the stomach has a manifold 
diagnostic value. By its aid we are able to diagnose a number of 
anatomical diseases of the stomach before the respective conditions 
make any other objective symptoms. There are'Other diseases of the 
stomach which otherwise never furnish any distinct symptoms at all : 
they can only be recognized by an examination of the process of 
digestion. On the other hand, certain nervous dyspepsias are distin- 
guished by a normal digestion which is in contrast with the severe 
subjective complaints. But even where a disease of the stomach — 
cancer of the pylorus, for instance — has been diagnosed with certainty 
by an external examination of the abdomen, a clear insight into the 
disturbances of the functions of the stomach which are caused by the 
anatomical lesion can only be obtained by a study of its contents. 
And in all these cases the examination furnishes valuable indications 
for treatment. 

EXAMINATION OF THE PROCESS OF DIGESTION. 

Preliminary Remarks upon Stomach- digestion and its Dis- 
turbances. — I. Physiologically, the stomach fulfils a threefold task — 

{a) It initiates the alterations of the starches and albuminous por- 
tions of the food into absorbable substances, and in a lesser degree 
also completes them. 

{b) It protects its contents for hours from fermentation and putre- 
faction during their stay within it. 

(c) It discharges its contents within a certain time, partly (but to a 
comparatively very small extent) by absorption, principally in the fol- 
lowing way : first, the fluid, and later the soHd, elements of its contents 
pass in separate portions through the pylorus into the duodenum. 

After a meal containing albumin and starches has been taken (we 
disregard fats, because they are not acted upon by the stomach), first 
there is a transformation of the starches, partly amylolytic, partly 
diastatic, produced by the fermentative action of the ptyahn of the 
saliva. Starch is converted into maltose or dextrose and achroo- and 
erythro-dextrin. Any cane-sugar that has been taken is inverted into 

1 See below. 2 ggg p 265. 



EXAMIXATION OF THE DIGESTIVE APPARATUS. 305 

dextrose. These processes go on rather rapidly, but are, however, 
usually interrupted before completion by the commencing hydro- 
chloric-acid acidification of the stomach-contents. Simultaneously, 
various micro-organisms — schizomycetes, which enter from the mouth 
and are always present in the stomach — produce a partial lactic-acid 
fermentation of the sugars present there, which are capable of fer- 
mentation : hence lactic acid is formed. 

This amylolytic period of digestion lasts a short time, varying in 
length according to the size of the meal ; on the average, it lasts three- 
quarters of an hour. As a matter of course, it is entirely absent if only 
meat is eaten ; then also there is no lactic acid. 

Immediately after food is taken the mucous membrane of the stomach 
begins to secrete muriatic acid and pepsin or propepsin,^ and the stom- 
ach-juice mixes with the alkaline chyme. But at first the muriatic acid 
is in combination, but after a period of time of variable length, on the 
average one-half to three-quarters of an hour, we have free muriatic 
acid. The amylolytic period is brought to a close, because the free 
acid destroys the ptyalin of the saliva. The lactic-acid fermentation 
too is soon afterward suppressed — i. c. as soon as the free hydrochloric 
acid of the gastric juice amounts to about O.i per cent, (to 0.07, accord- 
ing to some ; to 0.12 to 0.16, according to others), and now there begins 
the swelling and defibrination of the meat by the hydrochloric acid, and 
the hydrolytic splitting up of the albuminous substances by the enzym 
of the gastric juice, the pepsin. At the same time the bacteria are 
destroyed or made ineffective. 

We must now keep clearly in mind that the gastric juice secreted by 
the mucous membrane of the stomach — that is to say, by the glands of 
the fundus, which is strongly acid and contains hydrochloric acid and 
pepsin — acts on those parts of the gastric contents which are in contact 
with the walls of the stomach ; moreover, that the hydrochloric acid, 
diffusing into the parts of the gastric contents which lie farther away 
from the walls of the stomach, enters into combination with these. 
Therefore, we must assume that there is a peptonizing and disinfecting 
action of the hydrochloric acid on the masses which are carried along 
the walls of the stomach by its peristaltic movements, before the entire 
contents of the stomach (or a sample taken from it) contains any free 
acid. 

Therefore, the stomach-contents do not contain any free acid in the 
first stage of the secretion of the acid gastric juice, because the secreted 
hydrochloric acid is then in combination. In the first instance it is a 
fixed combination, in the ordinary sense, up to the neutralization of the 
existing alkali. This is followed by a looser combination with albu- 
moses and peptones in the formation of substances which may be called 
acid albumins. Farther, there is a loose combination with leucin, tyro- 
sin, and also with salts, particularly phosphates. Combinations of 
hydrochloric acid have an acid reaction, but pepsin has no digestive 
power if in contact with them. Only when the loose combination of 
hydrochloric acid with those substances is completed, and, besides, the 
stomach has gotten rid of a considerable part of the acid-dissolved 
albuminous substances, does free hydrochloric acid appear, and from 

1 See below. 
20 



308 SPECIAL DIAGNOSIS. 

cised its antiseptic and peptic power on those particles of food which 
are in contact with the stomach-wall. 

Until now, however, there has been unsatisfactorily appreciated the 
greatly significant circumstance that the different kinds of food, accord- 
ing to their physical and chemical properties, exercise a very different 
degree of stimulation of the secretion of hydrochloric acid and the motor 
activity of the stomach, both of the healthy and of the diseased organ. 
This fact forms one of the principal reasons why we cannot make our 
examination after every kind of meal if we wish to gain the most per- 
fect possible insight into the work of the stomach. It is necessary 
rather to introduce into the stomach a mixture of food the quality and 
quantity of whose constituents are exactly determined, thus to procure 
in this respect at least equal conditions for successive experiments. A 
meal given for the purpose of making an experiment in digestion is 
called a " test-meal." 

II. About six hours after a mixed meal of moderate quantity, much 
sooner after a smaller one, the stomach has become entirely empty or 
at most contains only small particles of food. In the interval until the 
next meal, in the great majority of healthy persons, it appears that the 
stomach contains a very scant amount of clear fluid, with a neutral 
reaction, but no muriatic acid or pepsin. 

The stomach-digestion of nurslings has as yet been very little 
studied. According to Leo, the fasting stomach of a nursling almost 
always contains free muriatic acid, while during digestion free muriatic 
acid cannot at all, or only after an hour, be demonstrated ; this is 
not because there is none secreted, but because it is neutralized by the 
milk. Leo always found rennet-ferment, excepting in one case where 
there was rennet-zymogen. After half an hour the greater portion of 
the milk has passed into the intestine, and in one or at most three 
hours the stomach is empty. Leo also thinks that the peptonizing of 
the milk in the stomach is a subordinate process. He regards the 
stomach as really a milk-reservoir, and as offering a barrier to patho- 
genic micro-organisms. 

III. The chief points in regard to the effect of pathological disturb- 
ances of the gastric secretion, of the motions of the stomach upon 
digestion, and the sterilization of the food and its further transportation 
into the intestine are as follows : 

Diminished secretion of hydrochloric acid and pepsin, which always 
goes parallel with it [Jiypacidity, subacidity), interferes with the swelling 
of the meat and the peptonization of the albumin, and also lowers the 
antifermentative action of the stomach upon its contents. The altera- 
tion of the starches might be normal, but, at any rate, it is almost 
always disturbed, because, in consequence of the scarcity of hydro- 
chloric acid, lactic acid is increased, and ultimately also butyric-acid 
fermentation, which quickly acidify the contents of the stomach even in 
a higher degree than takes place in normal digestion by free hydro- 
chloric acid. If lactic acid be very abundant, it may even peptonize the 
albuminous substances if pepsin, of which, as is well known, only a very 
small quantity is needed, is not too much diminished. The examination 
of the gastric contents at the height of digestion shows diminished free 
acid — deficiency of hydrocJiloric acid. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 305 

dextrose. These processes go on rather rapidly, but are, however, 
usually interrupted before completion by the commencing hydro- 
chloric-acid acidification of the stomach-contents. Simultaneously, 
various micro-organisms — schizomycetes, which enter from the mouth 
and are always present in the stomach — produce a partial lactic-acid 
fermentation of the sugars present there, which are capable of fer- 
mentation : hence lactic acid is formed. 

This amylolytic period of digestion lasts a short time, varying in 
length according to the size of the meal ; on the average, it lasts three- 
quarters of an hour. As a matter of course, it is entirely absent if only 
meat is eaten ; then also there is no lactic acid. 

Immediately after food is taken the mucous membrane of the stomach 
begins to secrete muriatic acid and pepsin or propepsin,^ and the stom- 
ach-juice mixes with the alkaline chyme. But at first the muriatic acid 
is in combination, but after a period of time of variable length, on the 
average one-half to three-quarters of an hour, we have free muriatic 
acid. The amylolytic period is brought to a close, because the free 
acid destroys the ptyalin of the saliva. The lactic-acid fermentation 
too is soon afterward suppressed — i. c. as soon as the free hydrochloric 
acid of the gastric juice amounts to about O.i per cent, (to 0.07, accord- 
ing to some ; to 0.12 to 0.16, according to others), and now there begins 
the swelling and defibrination of the meat by the hydrochloric acid, and 
the hydrolytic splitting up of the albuminous substances by the enzym 
of the gastric juice, the pepsin. At the same time the bacteria are 
destroyed or made ineffective. 

We must now keep clearly in mind that the gastric juice secreted by 
the mucous membrane of the stomach — that is to say, by the glands of 
the fundus, which is strongly acid and contains hydrochloric acid and 
pepsin — acts on those parts of the gastric contents which are in contact 
with the walls of the stomach ; moreover, that the hydrochloric acid, 
diffusing into the parts of the gastric contents which lie farther away 
from the walls of the stomach, enters into combination with these. 
Therefore, we must assume that there is a peptonizing and disinfecting 
action of the hydrochloric acid on the masses which are carried along 
the walls of the stomach by its peristaltic movements, before the entire 
contents of the stomach (or a sample taken from it) contains any free 
acid. 

Therefore, the stomach-contents do not contain any free acid in the 
first stage of the secretion of the acid gastric juice, because the secreted 
hydrochloric acid is then in combination. In the first instance it is a 
fixed combination, in the ordinary sense, up to the neutralization of the 
existing alkali. This is followed by a looser combination with albu- 
moses and peptones in the formation of substances which may be called 
acid albumins. Farther, there is a loose combination with leucin, tyro- 
sin, and also with salts, particularly phosphates. Combinations of 
hydrochloric acid have an acid reaction, but pepsin has no digestive 
power if in contact with them. Only when the loose combination of 
hydrochloric acid with those substances is completed, and, besides, the 
stomach has gotten rid of a considerable part of the acid-dissolved 
albuminous substances, does free hydrochloric acid appear, and from 

^ See below. 
20 



308 SPECIAL DIAGNOSIS. 

cised its antiseptic and peptic power on those particles of food which 
are in contact with the stomach-wall. 

Until now, however, there has been unsatisfactorily appreciated the 
greatly significant circumstance that the different kinds of food, accord- 
ing to their physical and chemical properties, exercise a very different 
degree of stimulation of the secretion of hydrochloric acid and the motor 
activity of the stomach, both of the healthy and of the diseased organ. 
This fact forms one of the principal reasons why we cannot make our 
examination after every kind of meal if we wish to gain the most per- 
fect possible insight into the work of the stomach. It is necessary 
rather to introduce into the stomach a mixture of food the quality and 
quantity of whose constituents are exactly determined, thus to procure 
in this respect at least equal conditions for successive experiments. A 
meal given for the purpose of making an experiment in digestion is 
called a " test-meal." 

II. About six hours after a mixed meal of moderate quantity, much 
sooner after a smaller one. the stomach has become entirely empty or 
at most contains only small particles of food. In the interval until the 
next meal, in the great majority of healthy persons, it appears that the 
stomach contains a very scant amount of clear fluid, with a neutral 
reaction, but no muriatic acid or pepsin. 

The stomach-digestion of nurslings has as yet been very little 
studied. According to Leo, the fasting stomach of a nursling almost 
always contains free muriatic acid, while during digestion free muriatic 
acid cannot at all, or only after an hour, be demonstrated ; this is 
not because there is none secreted, but because it is neutrahzed by the 
milk. Leo always found rennet-ferment, excepting in one case where 
there was rennet-zymogen. After half an hour the greater portion of 
the milk has passed into the intestine, and in one or at most three 
hours the stomach is empty. Leo also thinks that the peptonizing of 
the milk in the stomach is a subordinate process. He regards the 
stomach as really a milk-reservoir, and as offering a barrier to patho- 
genic micro-organisms. 

III. The chief points in regard to the effect of pathological disturb- 
ances of the gastric secretion, of the motions of the stomach upon 
digestion, and the sterilization of the food and its further transportation 
into the intestine are as follows : 

Diminished secretion of hydrochloric acid and pepsin, which always 
goes parallel with it {Jiypacidity, subacidity), interferes with the swelling 
of the meat and the peptonization of the albumin, and also lowers the 
antifermentative action of the stomach upon its contents. The altera- 
tion of the starches might be normal, but, at any rate, it is almost 
always disturbed, because, in consequence of the scarcity of hydro- 
chloric acid, lactic acid is increased, and ultimately also butyric-acid 
fermentation, which quickly acidify the contents of the stomach even in 
a higher degree than takes place in normal digestion by free hydro- 
chloric acid. If lactic acid be very abundant, it may even peptonize the 
albuminous substances if pepsin, of which, as is well known, only a very 
small quantity is needed, is not too much diminished. The examination 
of the gastric contents at the height of digestion shows diminished free 
acid — deficiency of Jiyd^'ocJUoric acid. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 309 

If at the height of digestion free hydrochloric acid be entirely absent, 
we call the condition aiiacidity. The condition is one of deficiency of 
hydrochloric acid, but not necessarily of complete absence of its secre- 
tion. In acidity the disturbances above mentioned are present in a 
higher degree. 

Considerable femnentation, or even putrefaction, develops in these 
cases, however, only when the chemical disturbance is combined with 
considerable lowering of the fnotor activity of the stomach, which cer- 
tainly is very frequently the case. Only when the gastric contents for 
some reason remain abnormally long in the stomach is there time for 
fermentation to take place. However, stagnation of the contents of 
the stomach alone, without diminution of the secretion of hydrochloric 
acid, may have this effect, because it may come to the point that the 
hydrochloric acid, in spite of its abundant secretion, is not sufficient to 
acidify the great quantities of material stagnant in the stomach. There 
is then hypacidity, and, following this, abnormal fermentations, notwith- 
standing abundance of hydrochloric acid. It is often difficult to make 
a correct diagnosis in these cases. 

Increase of hydrochloric acid, hyperacidity, step er acidity, causes a too 
early appearance of free hydrochloric acid, and hence shortens the 
amylolytic period of digestion ; and thus there are often, though not 
constantly, found during the whole period in which the food remains 
in the stomach physically unaltered portions of amylaceous food or 
larger quantities of unsplit starch — i. e. of starch which becomes blue 
when mixed with iodin. If the free hydrochloric acid exceeds 0.2 per 
cent, (and not infrequently it is as high as 0.4 per cent., sometimes even 
higher), the albuminous foods are peptonized as soon as, or sooner than, 
normal and more completely ; that is, the period of digestion is fre- 
quently shortened. The gastric contents are often strikingly thin and 
clear, perhaps in consequence of increased secretion of water from the 
walls of the stomach; the meat is more or less changed; the hydro- 
carbons are sometimes scarcely changed ; organic acids are absent or 
sparingly present. 

Some conditions of hydrochloric-acid hyperacidity, with accelerated 
evacuation of the contents of the stomach into the intestines, change 
after a time, by a motor paralysis of the stomach, into a condition of 
stagnation of food, followed by catarrh of the mucosa with hypacidity ; 
then the whole process is reversed. 

Diminution of hydrochloric acid generally seems to go parallel with 
a diminution of pepsin and milk-curdling ferment. On the other hand, 
this parallelism is generally not present when there is hyperacidity; 
with increase of hydrochloric acid there even appears to be an absence 
or deficiency of pepsin. Some cases, where the peptonization of the 
albuminous substances is diminished notwithstanding the increased free 
hydrochloric acid, can only be explained by these facts. 

It has been said above that the disturbances of the secretion of 
gastric juice are not seldom combined with diminution of the motor 
activity of the stomach ; then, without exception, the food remains in the 
stomach. Both the chemical and motor anomalies are sometimes the 
consequences of the same cause, as, for instance, gastric catarrh ; or 
the weakness is the direct consequence of abnormal chemical processes, 



312 SPECIAL DIAGNOSIS. 

exerts very little stimulation, particularly on their secretion of gastric 
juice, for we must assume that it is albuminous substances which chiefly 
stimulate its secretion. On the other hand, it imposes a comparatively 
slight task upon a stomach whose motive force is insufficient; and 
accordingly the results may be comparatively coo favorable as regards 
the motor activity of the stomach, for we must know how the organ 
disposes of amylaceous as well as of albuminous substances in order to 
understand how it performs its function. 

For this reason we have lately preferred the test-meal of meat and 
starches. Of these several have been suggested. That of Leube con- 
sists of a plate of water soup, a moderate amount of beefsteak, and a 
little white bread. Kussmaul's test-meal, mentioned several times by 
Fleiner in his writings, seems to us to be more practical still : 250 
gm. of strained barley soup, 200 gm. of beefsteak, 200 gm. of mashed 
potatoes. Here the amount of albumin is somewhat regulated by the 
weight, and a similar arrangement of the conditions of the experiment 
seems to me to be indispensable. 

Normally, Leube's test-meal has left the stomach after seven hours 
at the latest, often after five or six hours. The maximum of hydro- 
chloric acid is reached about one to two hours before the time of 
complete evacuation of the stomach. 

After Kussmaul-Fleiner's test-meal the stomach is usually empty 
somewhat earlier, after five to six hours, and the maximum of hydro- 
chloric acid occurs three to three and a half hours from the time of 
taking the meal. 

Evacuation or washing out the fasting stomach in the morning and 
the introduction of a test-meal one or more successive days, with 
attendant examination of the duration of digestion and examination of 
the gastric contents at the height of digestion, are almost always suf- 
ficient, combined with the other symptoms, to form a correct opinion 
about the function of the stomach, so far as that is in any way possible 
with our present knowledge. All other methods which have been sug- 
gested for an examination of the gastric digestion may be set aside ; 
nevertheless, we shall mention some of them later on. In addition, we 
remark here that even an exact determination of the duration of diges- 
tion after a test-meal is usually unnecessary, so that the examiner can 
generally be content with the introduction of the sound into the fasting 
stomach at the supposed height of digestion of the test-meal. In cer- 
tain cases the stomach is found already empty at the time when the 
height of digestion should be expected. That would indicate an ac- 
celeration of the evacuation of the stomach, and that the duration was 
already at the limit of normal digestion. The next time the sound 
would be introduced an hour earlier. 

Method of Abstracting and Examining the Stomach -con- 
tents. — Contraindications to the use of the sound are — a considerable 
hemorrhage from the stomach a short time previous ; a slight loss of 
blood does not forbid its use if the stomach be full, but it must not be 
employed with the organ empty. Great general debility by diseases 
of the stomach ought not to prevent its use, but it is sometimes better 
to strengthen the patient first by artificial alimentation. As regards 
diseases of the heart and blood-vessels and affections of the lungs no 



\ 



EXAMINATION OF THE DIGESTIVE APPARATUS. 309 

If at the height of digestion free hydrochloric acid be entirely absent, 
we call the condition anacidity. The condition is one of deficiency of 
hydrochloric acid, but not necessarily of complete absence of its secre- 
tion. In acidity the disturbances above mentioned are present in a 
higher degree. 

Considerable fermentation, or even putrefaction, develops in these 
cases, however, only when the chemical disturbance is combined with 
considerable lowering of the motor activity of the stomach, which cer- 
tainly is very frequently the case. Only when the gastric contents for 
some reason remain abnormally long in the stomach is there time for 
fermentation to take place. However, stagnation of the contents of 
the stomach alone, without diminution of the secretion of hydrochloric 
acid, may have this effect, because it may come to the point that the 
hydrochloric acid, in spite of its abundant secretion, is not sufficient to 
acidify the great quantities of material stagnant in the stomach. There 
is then Jiypacidity, and, following this, abnormal fermentations, notwith- 
standing abundance of hydrochloric acid. It is often difficult to make 
a correct diagnosis in these cases. 

Increase of hydrochloric acid, hyperacidity, superacidity, causes a too 
early appearance of free hydrochloric acid, and hence shortens the 
amylolytic period of digestion ; and thus there are often, though not 
constantly, found during the whole period in which the food remains 
in the stomach physically unaltered portions of amylaceous food or 
larger quantities of unsplit starch — i. e. of starch which becomes blue 
when mixed with iodin. If the free hydrochloric acid exceeds 0.2 per 
cent, (and not infrequently it is as high as 0.4 per cent., sometimes even 
higher), the albuminous foods are peptonized as soon as, or sooner than, 
normal and more completely ; that is, the period of digestion is fre- 
quently shortened. The gastric contents are often strikingly thin and 
clear, perhaps in consequence of increased secretion of water from the 
walls of the stomach ; the meat is more or less changed ; the hydro- 
carbons are sometimes scarcely changed ; organic acids are absent or 
sparingly present. 

Some conditions of hydrochloric-acid hyperacidity, with accelerated 
evacuation of the contents of the stomach into the intestines, change 
after a time, by a motor paralysis of the stomach, into a condition of 
stagnation of food, followed by catarrh of the mucosa with hypacidity ; 
then the whole process is reversed. 

Diminution of hydrochloric acid generally seems to go parallel with 
a diminution of pepsin and rhilk-curdling ferment. On the other hand, 
this parallelism is generally not present when there is hyperacidity; 
with increase of hydrochloric acid there even appears to be an absence 
or deficiency of pepsin. Some cases, where the peptonization of the 
albuminous substances is diminished notwithstanding the increased free 
hydrochloric acid, can only be explained by these facts. 

It has been said above that the disturbances of the secretion of 
gastric juice are not seldom combined with diminution of the motor 
activity of tJie stomach ; then, without exception, the food remains in the 
stomach. Both the chemical and motor anomalies are sometimes the 
consequences of the same cause, as, for instance, gastric catarrh ; or 
the weakness is the direct consequence of abnormal chemical processes. 



312 SPECIAL DIAGNOSIS. 

exerts very little stimulation, particularly on their secretion of gastric 
juice, for we must assume that it is albuminous substances which chiefly 
stimulate its secretion. On the other hand, it imposes a comparatively 
slight task upon a stomach whose motive force is insufficient ; and 
accordingly the results may be comparatively coo favorable as regards 
the motor activity of the stomach, for we must know how the organ 
disposes of amylaceous as well as of albuminous substances in order to 
understand how it performs its function. 

For this reason we have lately preferred tJie test-meal of meat and 
starches. Of these several have been suggested. That of Leube con- 
sists of a plate of water soup, a moderate amount of beefsteak, and a 
little white bread. Kussmaul's test-meal, mentioned several times by 
Fleiner in his writings, seems to us to be more practical still : 250 
gm. of strained barley soup, 200 gm. of beefsteak, 200 gm. of mashed 
potatoes. Here the amount of albumin is somewhat regulated by the 
weight, and a similar arrangement of the conditions of the experiment 
seems to me to be indispensable. 

Normally, Leube's test-meal has left the stomach after seven hours 
at the latest, often after five or six hours. The maximum of hydro- 
chloric acid is reached about one to two hours before the time of 
complete evacuation of the stomach. 

After Kussmaul-Fleiner's test-meal the stomach is usually empty 
somewhat earlier, after five to six hours, and the maximum of hydro- 
chloric acid occurs three to three and a half hours from the time of 
taking the meal. 

Evacuation or washing out the fasting stomach in the morning and 
the introduction of a test-meal one or more successive days, with 
attendant examination of the duration of digestion and examination of 
the gastric contents at the height of digestion, are almost always suf- 
ficient, combined with the other symptoms, to form a correct opinion 
about the function of the stomach, so far as that is in any way possible 
with our present knowledge. All other methods which have been sug- 
gested for an examination of the gastric digestion may be set aside ; 
nevertheless, we shall mention some of them later on. In addition, we 
remark here that even an exact determination of the duration of diges- 
tion after a test-meal is usually unnecessary, so that the examiner can 
generally be content with the introduction of the sound into the fasting 
stomach at the supposed height of digestion of the test-meal. In cer- 
tain cases the stomach is found already empty at the time when the 
height of digestion should be expected. That would indicate an ac- 
celeration of the evacuation of the stomach, and that the duration was 
ah'eady at the limit of normal digestion. The next time the sound 
would be introduced an hour earlier. 

Method of Abstracting and Examining the Stomach-con- 
tents. — Contraindications to the use of the sound are — a considerable 
hemorrhage from the stomach a short time previous ; a slight loss of 
blood does not forbid its use if the stomach be full, but it must not be 
employed with the organ empty. Great general debility by diseases 
of the stomach ought not to prevent its use, but it is sometimes better 
to strengthen the patient first by artificial alimentation. As regards 
diseases of the heart and blood-vessels and affections of the lunes no 



EXAMINATION OF THE DIGESTIVE APPARATUS. 313 

rules can be given here, more especially as the danger is frequently in- 
fluenced by the psychical behavior (excitement, anxiety) of the patient 
during the use of the sound. Aneurysms without exception contra- 
indicate the introduction of the sound. 

Soft stomach-tubes must exclusively be used, and the best are the 
English patent sounds of Jaques, Nos. 20 to 22. They are of excel- 
lent material, but have the disadvantage that the eyes are too sharp- 
edged and often too small. It is necessary, therefore, to have the eyes 
made larger and burnt smoothly before using them. The use of a 
mandrin in introducing the sound is decidedly objectionable. 

It is well to put over the upper end of the sound a so-called biting 
ring of hard rubber, which the patient holds fast with his teeth as soon 
as the sound is in place ; but the ring must fit the sound closely. 

It is very much to be recommended to ascertain on the respective 
patients before the first introduction of the sound how far it must be 
introduced to fully reach the stomach, but also not any farther than 
necessary. Mark the spinal process of the ninth dorsal vertebra ; place 
the sound with its upper eye on the marked point and measure along 
the back and past the side of the head to the line of the incisors, 
marking the place of the latter on the sound by the dermatograph. If 
the sound is then introduced up to the mark, it is certain to have 
reached the lumen of the stomach if the cardia be not located abnor- 
mally deep. If it is, a corresponding portion must be added by chang- 
ing the mark. 

We always moisten the sound, at least at the first introduction, with 
a little glycerin. Others do not do so, but certainly it is somewhat 
preferable, and never does any harm. In children it is particularly 
adapted to make the sound more acceptable. 

The sound may be introduced in either of two ways : Make the 
patient raise his head a little ; then the operator grasps the sound with 
the fingers of the right hand as one holds a pen ; put the index and 
middle fingers upon the tongue, and pass the sound under them till 
the end of the sound reaches nearly to the end of the tongue ; here 
press the sound down a little, and then push it on moderately rapidly 
and draw back the hand slowly^ asking the patient at the same time to 
swallow. Or the sound is pushed without the aid of the left hand, but 
in this case, in the first place, the patient must raise his head very 
much until the point of the sound passes over the root of the tongue. 
In this instant the patient brings his head to the normal position and 
at the same time swallows. There is resistance at the cricoid cartilage 
or from spasm of the glottis, both of which can always be easily over- 
come. If the patient breathes badly, ask him to say ah. This diverts 
his attention, and is particularly of value if, as extremely rarely 
happens, the point of the sound has entered the larynx and rests 
there. 

The operator must not remove his hand from the sound after it has 
been introduced as far as the mark, nor must he allow the patient to 
hold it unless perfectly quiet and steady. It is best for patients who 
introduce the sound themselves to fasten it to their hand with a string, 
lest, as has sometimes happened, it slip into the stomach. 

Great excitement, disturbed breathing, or violent vomiting past 



3l6 SPECIAL DIAGNOSIS. 

(organic acid, particularly butyric, also acetic acid) ; in alkaline fer- 
mentation they may smell putrid, and in rare cases like sulphuretted 
hydrogen gas. 

Examination by the Microscope. — At the height of normal diges- 
tion the microscope reveals still defibrinated remains of meat, with the 
transverse striae partly preserved ; the rest is mostly indistinguishable 
detritus and a small admixture of mucus. 

Pathologically, there are found the above-mentioned tough particles 
of meat (hypacidity), or remains of roll, distinct grains of starch 
(hyperacidity, severe hypacidity, and fermentation), great quantities of 
mucus (catarrh). White blood-cells, according to their quantity, 
indicate slightly suppurating surfaces (ulcer, carcinoma) or a ruptured 
abscess (phlegmon). The significance of blood has been mentioned 
before ; blood greatly altered (macroscopically, " coffee-grounds " and 
the like) can never be positively recognized by the microscope ; it 
requires the hemin test. A few epithelial cells do not mean anything ; 
on the contrary, masses . of concentrically arranged epithelial cells 
awaken a strong suspicion of carcinoma. If possible, it is worth while 
to pick up these cells, harden them in formal in the bottom of a test- 
tube, and make sections of them by using the freezing microtome or 
imbedding them in celloidin. Scliizomycetes are always found, and in 
the stagnating gastric contents they exist in great quantities, but neither 
their quantity nor their vitality is of special diagnostic significance, and 
also to specify them has no independent value for diagnosis. Sprouting 
fungi are sometimes seen in remarkably large quantities when there is 
much fermentation. Sarcinco, both the large and small forms, are found 
almost solely in severe disturbance of transportation. 

Chemical Examination. — For the chemical examination a portion 
of the gastric contents is triturated in a porcelain basin and then run 
through a wire sieve. The examination of an untriturated filtrate gives 
inexact results in regard to hydrochloric acid, since it exists in a more 
concentrated form in solid particles, particularly in small pieces of meat, 
than in the liquid. 

The reaction of the filtrate is tested by dipping a slip of litmus- 
paper into it. It is almost always acid. The acidity may be caused 
by loosely combined, or by free and loosely combined, hydrochloric 
acid, or by free organic acids, or, finally, as is mostly the case, by 
hydrochloric acid and organic acids. Acid salts also give an acid 
reaction, but they do not cut any figure in the different test-meals. 
Next, the examination is directed to a qualitative determination of free 
hydrochloric acid and free organic acids. Among these the volatile 
ones (butyric, acetic, valerianic acids) are, as has already been mentioned, 
recognized by their odor, but at the same time they are more difficult 
to demonstrate chemically ; therefore it suffices to recognize them by 
the sense of smell. For free hydrochloric acid and lactic acid, however, 
we have simple color reactions. The examination is as follows : 

If litmus-paper is reddened, the test for free hydrochloric acid 
follows. Among the many methods given, only those with congo-red 
or congo-papcr and phloroglucin-vanillin deserve to be mentioned in 
detail. 

For the test with congo-red \nq are indebted to Dr. Hiibner of Mann- 



EXAMINATION OF THE DIGESTIVE APPARATUS. 313 

rules can be given here, more especially as the danger is frequently in- 
fluenced by the psychical behavior (excitement, anxiety) of the patient 
during the use of the sound. Aneurysms without exception contra- 
indicate the introduction of the sound. 

Soft stomach-tubes must exclusively be used, and the best are the 
English patent sounds of Jaques, Nos, 20 to 22. They are of excel- 
lent material, but have the disadvantage that the eyes are too sharp- 
edged and often too small. It is necessary, therefore, to have the eyes 
made larger and burnt smoothly before using them. The use of a 
mandrin in introducing the sound is decidedly objectionable. 

It is well to put over the upper end of the sound a so-called biting 
ring of hard rubber, which the patient holds fast with his teeth as soon 
as the sound is in place ; but the ring must fit the sound closely. 

It is very much to be recommended to ascertain on the respective 
patients before the first introduction of the sound how far it must be 
introduced to fully reach the stomach, but also not any farther than 
necessary. Mark the spinal process of the ninth dorsal vertebra; place 
the sound with its upper eye on the marked point and measure along 
the back and past the side of the head to the line of the incisors, 
marking the place of the latter on the sound by the dermatograph. If 
the sound is then introduced up to the mark, it is certain to have 
reached the lumen of the stomach if the cardia be not located abnor- 
mally deep. If it is, a corresponding portion must be added by chang- 
ing the mark. 

We always moisten the sound, at least at the first introduction, with 
a little glycerin. Others do not do so, but certainly it is somewhat 
preferable, and never does any harm. In children it is particularly 
adapted to make the sound more acceptable. 

The sound may be introduced in either of two ways : Make the 
patient raise his head a little ; then the operator grasps the sound with 
the fingers of the right hand as one holds a pen ; put the index and 
middle fingers upon the tongue, and pass the sound under them till 
the end of the sound reaches nearly to the end of the tongue ; here 
press the sound down a little, and then push it on moderately rapidly 
and draw back the hand slowly, asking the patient at the same time to 
swallow. Or the sound is pushed without the aid of the left hand, but 
in this case, in the first place, the patient must raise his head very 
much until the point of the sound passes over the root of the tongue. 
In this instant the patient brings his head to the normal position and 
at the same time swallows. There is resistance at the cricoid cartilage 
or from spasm of the glottis, both of which can always be easily over- 
come. If the patient breathes badly, ask him to say a]i. This diverts 
his attention, and is particularly of value if, as extremely rarely 
happens, the point of the sound has entered the larynx and rests 
there. 

The operator must not remove his hand from the sound after it has 
been introduced as far as the mark, nor must he allow the patient to 
hold it unless perfectly quiet and steady. It is best for patients w^ho 
introduce the sound themselves to fasten it to their hand with a string, 
lest, as has sometimes happened, it slip into the stomach. 

Great excitement, disturbed breathing, or violent vomiting past 



3l6 SPECIAL DIAGNOSIS. 

(organic acid, particularly butyric, also acetic acid) ; in alkaline fer- 
mentation they may smell putrid, and in rare cases like sulphuretted 
hydrogen gas. 

Examination by the Microscope. — At the height of normal diges- 
tion the microscope reveals still defibrinated remains of meat, with the 
transverse striae partly preserved ; the rest is mostly indistinguishable 
detritus and a small admixture of mucus. 

Pathologically, there are found the above-mentioned tough particles 
of meat (hypacidity), or remains of roll, distinct grains of starch 
(hyperacidity, severe hypacidity, and fermentation), great quantities of 
mucus (catarrh). White blood-cells, according to their quantity, 
indicate slightly suppurating surfaces (ulcer, carcinoma) or a ruptured 
abscess (phlegmon). The significance of blood has been mentioned 
before ; blood greatly altered (macroscopically, " coffee-grounds " and 
the like) can never be positively recognized by the microscope ; it 
requires the hemin test. A few epithelial cells do not mean anything ; 
on the contrary, masses of concentrically arranged epithelial cells 
awaken a strong suspicion of carcinoma. If possible, it is worth while 
to pick up these cells, harden them in formal in the bottom of a test- 
tube, and make sections of them by using the freezing microtome or 
imbedding them in celloidin. ScJiizomycetes are always found, and in 
the stagnating gastric contents they exist in great quantities, but neither 
their quantity nor their vitality is of special diagnostic significance, and 
also to specify them has no independent value for diagnosis. Sprouting 
fungi are sometimes seen in remarkably large quantities when there is 
much fermentation. Sarcince, both the large and small forms, are found 
almost solely in severe disturbance of transportation. 

Chemical Examination. — For the chemical examination a portion 
of the gastric contents is triturated in a porcelain basin and then run 
through a wire sieve. The examination of an untriturated filtrate gives 
inexact results in regard to hydrochloric acid, since it exists in a more 
concentrated form in solid particles, particularly in small pieces of meat, 
than in the Hquid. 

The reaction of the filtrate is tested by dipping a slip of litmus- 
paper into it. It is almost always acid. The acidity may be caused 
by loosely combined, or by free and loosely combined, hydrochloric 
acid, or by free organic acids, or, finally, as is mostly the case, by 
hydrochloric acid and organic acids. Acid salts also give an acid 
reaction, but they do not cut any figure in the different test-meals. 
Next, the examination is directed to a qualitative determination of free 
hydrochloric acid and free organic acids. Among these the volatile 
ones (butyric, acetic, valerianic acids) are, as has already been mentioned, 
recognized by their odor, but at the same time they are more difficult 
to demonstrate chemically ; therefore it suffices to recognize them by 
the sense of smell. For free hydrochloric acid and lactic acid, however, 
we have simple color reactions. The examination is as follows : 

If htmus-paper is reddened, the test for free hydrochloric acid 
follows. Among the many methods given, only those with congo-red 
or congo-paper and phloroglucin-\'anilHn deserve to be mentioned in 
detail. 

For the test ivith congo-red \wt are indebted to Dr. Hiibner of Mann- 



EXAMINATION OF THE DIGESTIVE APPARATUS. 317 

heim. It is best to use congo-paper which has been saturated with 
an exactly i : 1000 solution of congo-red. If this paper is dyed a clear 
sky-blue by a drop of the filtrate, there is abundant free hydrochloric 
acid present. An indistinct blue, a blue-black, or a violet color de- 
velops if there are present, besides a little free acid, abundant acids of 
the fatty-acid series, particularly lactic acid, or if these alone are present 
and hydrochloric acid is absent. The test, therefore, has only a qualified 
value ; even when only free hydrochloric acid is present it is not very 
distinct. 

The phloroglucin-vanillin reaction is safer and more distinct. The 
reagent consists of phloroglucin 2.0, vanillin i.o, absolute alcohol 30.0. 
One to two drops are placed on a little china porcelain plate or small 
spoon ; mix with it an equal amount of the filtrate ; distribute the 
liquid and heat slowly. When drying, if free hydrochloric acid is 
present, there appears a bright-red color ; or if there is but little free 
hydrochloric acid, a rose-red color. If there is no free hydrochloric 
acid present, the drying liquid remains brown throughout. The re- 
action takes place even with only 0.05 per thousand of hydrochloric 
acid, and is therefore a very sensitive test. Large quantities of salts 
prevent the reaction, but these are not present in test-meals. By 
organic acids, even in the highest concentration, the reaction does not 
take place. It would only appear in the rare case of the presence of 
sulphuretted hydrogen (thus, for instance, in marked putrefaction, or 
after having taken sulphurous waters or putrid eggs). On the whole, 
then, we may consider the test absolutely safe for free hydrochloric 
acid, but not also for loosely combined hydrochloric acid, and it is 
therefore sufficient to make this test alone. 

The tropaolin reaction is not so certain, and in many places is not 
used any more. The reagent is a saturated alcoholic solution of 
tropaolin 00, of which a few drops with double the quantity of gas- 
tric contents are placed on a Httle porcelain saucer. They are dis- 
tributed by agitation, and after pouring off the surplus slowly heated. 
Free, not loosely combined, hydrochloric acid gives a lilac-red luster 
even with 0.5 per thousand ; but free organic acids give the same re- 
action, although only in a concentration of more than 0.6 per cent. — a 
condition which scarcely occurs in the gastric contents. 

Of the numerous other tests we only mention : The reaction with 
methyl-violet, which is applied as follows : two reagent-glasses are half- 
filled with a transparent solution of methyl-violet, and to this some of 
the filtrate is added. Free HCl colors methyl-violet blue. The reaction 
is not very distinct nor is it very reliable ; it can be imitated by table- 
salt, and it may be concealed by albuminate, peptone, etc. There are 
also to be named : blue ultramarine and resorcin, recently recommended 
by Boas (resorcin 5 parts, sugar 3 parts, dilute spirit to lOO parts). 

All these color reactions indicate only free hydrochloric acid, not the 
loosely combine:! acid also. This latter, indeed, reddens litmus-paper, 
but does not respond to these reagents of which we have been speak- 
ing. But as the free hydrochloric acid alone is concerned in the peptoni- 
zation of albuminous substances, the reactions for free acid, particularly 
the phloroglucin-vanillin test, indicate directly whether the gastric juice 
possesses the power to digest albumin or not. 



320 SPECIAL DIAGNOSIS. 

wire sieve. If too thick, mix with distilled water till a thin liquid is 
formed. Then add from a burette sufficient of a decinormal [^ per 
Gent.] solution of caustic soda to wipe out every trace of the phloro- 
glucin reaction from every drop of the liquid. From the amount of 
soda solution used the amount of free hydrochloric acid is calculated 
as follows : i c.cm. of the decinormal solution of caustic soda = 
0.00365 hydrochloric acid. For instance, there have been used 5 c.cm. 
of the soda solution, which would correspond to 5.0 X 0.00365 = 
0.01825 hydrochloric acid. Hence in 10 c.cm. there were 0.018 of 
free hydrochloric acid in 100 c.cm.; that is, therefore, o.io— /. e. there 
were 0.18 per cent, of free hydrochloric acid. 

This determination of the free hydrochloric acid — or, if you will, of 
the excess of hydrochloric acid — is a tolerably exact and useful one. 
Unfortunately, it takes up much time by the necessary, continuous 
repetition of the time-consuming phloroglucin reaction. Fleiner has 
therefore suggested a simpHfication which can be recommended : Be- 
fore titration add to the portion of the gastric contents 25 drops of 
phloroglucin-vanillin ; mix carefully and titrate, add the mixture drop 
by drop upon a porcelain spoon while carefully heating it, and sharply 
observe the play of colors. 

In like manner, by titration, if the qualitative examination has not 
revealed any free hydrochloric acid, one may find how much hydro- 
chloric acid must be added before free hydrochloric acid appears. 
Strictly speaking, this is a determination of how much hydrochloric 
acid is lacking to produce a loose saturation (of the albuminates, etc.), 
and we call the deficient quantity deficiency of hydrochloric acid. 

Method of Procedure. — Prepare a pure normal solution of hydro- 
chloric acid — i. e. 10 c.cm. of which are exactly neutralized by 10 c.cm. 
of decinormal solution of caustic soda. Now to 10 c.cm. of the chyme 
prepared and diluted with water, as mentioned above, add normal 
hydrochloric acid from a burette till the phloroglucin reaction gives 
a positive result. The hydrochloric-acid deficiency is calculated as 
applied to lOO c.cm. directly from the normal hydrochloric-acid solu- 
tion used : i c.cm. of the decinormal solution of hydrochloric acid = 
0.00365 hydrochloric acid. 

Here, too, the simplification suggested by Fleiner may be employed : 
Mix the chyme with 25 drops of phloroglucin-vanillin before the com- 
mencement of titration. 

The determination of the total amount of acid in the chyme has little 
value compared with these examinations. Nevertheless, it is occasion- 
ally of interest to express in numbers the sometimes astonishingly high 
acid values which occur in abnormal fermentations. 

Method of Procedure. — Add to 10 c.cm. of the chyme (diluted while 
being stirred) a few drops of a i per cent, alcoholic solution of phe- 
nolphthalein, which is colorless in acid reaction, but beautifully rose-red 
in alkaline. Add from the burette decinormal solution of caustic soda 
till a reddish color-tone appears. The acidity is expressed by the 
amount of the soda solution referred to 100 or looo c.cm. of gastric 
contents. 

In the total amount of acidity organic acids as well as hydrochloric 
acid almost always participate. It is specially to be observed that not 



EXAMINATION OF THE DIGESTIVE APPARATUS. 317 

heim. It is best to use congo-paper which has been saturated with 
an exactly i : 1000 solution of congo-red. If this paper is dyed a clear 
sky-blue by a drop of the filtrate, there is abundant free hydrochloric 
acid present. An indistinct blue, a blue-black, or a violet color de- 
velops if there are present, besides a little free acid, abundant acids of 
the fatty-acid series, particularly lactic acid, or if these alone are present 
and hydrochloric acid is absent. The test, therefore, has only a qualified 
value ; even when only free hydrochloric acid is present it is not very 
distinct. 

The phloroghicin-vanillin reaction is safer and more distinct. The 
reagent consists of phloroglucin 2.0, vanillin i.o, absolute alcohol 30.0. 
One to two drops are placed on a little china porcelain plate or small 
spoon ; mix with it an equal amount of the filtrate ; distribute the 
liquid and heat slowly. When drying, if free hydrochloric acid is 
present, there appears a bright-red color ; or if there is but little free 
hydrochloric acid, a rose-red color. If there is no free hydrochloric 
acid present, the drying liquid remains brown throughout. The re- 
action takes place even with only 0.05 per thousand of hydrochloric 
acid, and is therefore a very sensitive test. Large quantities of salts 
prevent the reaction, but these are not present in test-meals. By 
organic acids, even in the highest concentration, the reaction does not 
take place. It would only appear in the rare case of the presence of 
sulphuretted hydrogen (thus, for instance, in marked putrefaction, or 
after having taken sulphurous waters or putrid eggs). On the whole, 
then, we may consider the test absolutely safe for free hydrochloric 
acid, but not also for loosely combined hydrochloric acid, and it is 
therefore sufficient to make this test alone. 

The tropaolin reaction is not so certain, and in many places is not 
used any more. The reagent is a saturated alcoholic solution of 
tropaolin OO, of which a few drops with double the quantity of gas- 
tric contents are placed on a little porcelain saucer. They are dis- 
tributed by agitation, and after pouring off the surplus slowly heated. 
Free, not loosely combined, hydrochloric acid gives a lilac-red luster 
even with 0.5 per thousand ; but free organic acids give the same re- 
action, although only in a concentration of more than 0.6 per cent. — a 
condition which scarcely occurs in the gastric contents. 

Of the numerous other tests we only mention : The reaction with 
methyl-violet, which is applied as follows : two reagent-glasses are half- 
filled with a transparent solution of methyl-violet, and to this some of 
the filtrate is added. Free HCl colors methyl-violet blue. The reaction 
is not very distinct nor is it very reliable ; it can be imitated by table- 
salt, and it may be concealed by albuminate, peptone, etc. There are 
also to be named : blue ultramarine and resorcin, recently recommended 
by Boas (resorcin 5 parts, sugar 3 parts, dilute spirit to lOO parts). 

All these color reactions indicate only free hydrochloric acid, not the 
loosely combinec! acid also. This latter, indeed, reddens litmus-paper, 
but does not respond to these reagents of which we have been speak- 
ing. But as the free hydrochloric acid alone is concerned in the peptoni- 
zation of albuminous substances, the reactions for free acid, particularly 
the phloroglucin-vanillin test, indicate directly whether the gastric juice 
possesses the power to digest albumin or not. 



320 SPECIAL DIAGNOSIS. 

wire sieve. If too thick, mix with distilled water till a thin liquid is 
formed. Then add from a burette sufficient of a decinormal [^ per 
cent.] solution of caustic soda to wipe out every trace of the phloro- 
glucin reaction from every drop of the liquid. From the amount of 
soda solution used the amount of free hydrochloric acid is calculated 
as follows : i c.cm. of the decinormal solution of caustic soda = 
0.00365 hydrochloric acid. For instance, there have been used 5 c.cm. 
of the soda solution, which would correspond to 5.0 X O.OO365 ^ 
0.01825 hydrochloric acid. Hence in 10 c.cm. there were 0.018 of 
free hydrochloric acid in lOO c.cm.; that is, therefore, O.IO — i. e. there 
were 0.18 per cent, of free hydrochloric acid. 

This determination of the free hydrochloric acid — or, if you will, of 
the excess of hydrochloric acid — is a tolerably exact and useful one. 
Unfortunately, it takes up much time by the necessary, continuous 
repetition of the time-consuming phloroglucin reaction. Fleiner has 
therefore suggested a simplification which can be recommended : Be- 
fore titration add to the portion of the gastric contents 25 drops of 
phloroglucin-vanillin ; mix carefully and titrate, add the mixture drop 
by drop upon a porcelain spoon while carefully heating it, and sharply 
observe the play of colors. 

In Hke manner, by titration, if the qualitative examination has not 
revealed any free hydrochloric acid, one may find how much hydro- 
chloric acid must be added before free hydrochloric acid appears. 
Strictly speaking, this is a determination of how much hydrochloric 
acid is lacking to produce a loose saturation (of the albuminates, etc.), 
and we call the deficient quantity deficiency of hydrochloric acid. 

Method of Procedure. — Prepare a pure normal solution of hydro- 
chloric acid — /. e. \o c.cm. of which are exactly neutrahzed by 10 c.cm. 
of decinormal solution of caustic soda. Now to 10 c.cm. of the chyme 
prepared and diluted with water, as mentioned above, add normal 
hydrochloric acid from a burette till the phloroglucin reaction gives 
a positive result. The hydrochloric-acid deficiency is calculated as 
applied to 100 c.cm. directly from the normal hydrochloric-acid solu- 
tion used : i c.cm. of the decinormal solution of hydrochloric acid ^ 
0.00365 hydrochloric acid. 

Here, too, the simplification suggested by Fleiner may be employed : 
Mix the chyme with 25 drops of phloroglucin-vanillin before the com- 
mencement of titration. 

The determination of the total amount of acid in the chyme has little 
value compared with these examinations. Nevertheless, it is occasion- 
ally of interest to express in numbers the sometimes astonishingly high 
acid values which occur in abnormal fermentations. 

Method of Procedure. — Add to 10 c.cm. of the chyme (diluted while 
being stirred) a few drops of a i per cent, alcoholic solution of phe- 
nolphthalcin, which is colorless in acid reaction, but beautifully rose-red 
in alkaline. Add from the burette decinormal solution of caustic soda 
till a reddish color-tone appears. The acidity is expressed by the 
amount of the soda solution referred to 100 or 1000 c.cm. of gastric 
contents. 

In the total amount of acidity organic acids as well as hydrochloric 
acid almost always participate. It is specially to be observed that not 



EXAMINATION OF THE DIGESTIVE APPARATUS. 32 1 

only where free hydrochloric acid besides organic acids appear, but 
even where free hydrochloric acid is absent, hydrochloric acid gener- 
ally participates in the acidity, because the hydrochloric combinations 
of albumin react acid. 

We generally have to refrain from the direct quantitative determina- 
tion of organic acids because of the time required and their difficulty. 
Indirectly, we may approximately find them by determining the total 
acidity in 10 c.cm. of chyme, then make an ethereal extract in the 
separating funnel, and again determine the acidity. The hydrochloric- 
acid acidity is approximately ascertained, and, by subtracting this from 
the total quantity of acidity, we arrive at the acidity of organic acids. 
Examining the Digestion in an Incubator. — The examination of 
the digestive power of the gastric juice is of especial value for demon- 
strating pepsin. At any rate, experience shows that when there is 
free muriatic acid pepsin is usually present ; on the other hand, when 
muriatic acid is absent no pepsin is present, for the reason that the 
mucous membrane of the stomach does not secrete pepsin itself, but 
secretes its zymogen, propepsin, and because muriatic acid has the 
exclusive, or at least the chief, power to form pepsin out of propepsin. 
For these reasons it may suffice, in most cases, to examine for muri- 
atic acid alone. But the thorough examination is of the greatest value 
for arriving at a complete judgment. 

We test the digestive power of the gastric juice upon a piece of the 
white of a hard-boiled ^'g'g. A piece about a centimeter square and a 
millimeter thick placed in a reagent-glass full of normal stomach-fluid 
should be dissolved in about an hour. If the solution is delayed or 
does not take place at all, it proves that there is a deficiency in the 
normal amount of pepsin only when wx are able to determine that 
there is also a deficiency in muriatic acid. For this reason it is best 
to conduct the examination simultaneously in two reagent- glasses, to 
one of which a few drops of HCl have been added. 

The coagulating effect of the gastric juice — that is to say, of the 
rennet-ferment — upon the casein of milk is proved by the fact that at 
the temperature of the body neutralized stomach-filtrate, with neutral 
or amphoteric milk, is coagulated : in fifteen to thirty minutes, if the 
rennet-ferment is present, there is coagulation of the casein. This 
test, it seems, can generally be omitted if it concerns nurslings, in 
whom it is of special interest, for it has been shown that when free 
HCl and pepsin are present the rennet-ferment is never absent ; even in 
most cases of absence of both the others rennet-ferment indeed seems 
not to be met with, but rennet-zymogen, which requires muriatic acid 
in order to transform it into rennet-ferment. In order to prove the 
presence of rennet-zymogen in gastric juice which is deficient in HCl 
and rennet-ferment, we supply the deficiency by adding HCl, and then 
allow it to stand in an incubator for two hours, after which we apply 
the test for the ferment mentioned above. In atrophy of the mucous 
membrane of the stomach there is entire absence of rennet-zymogen, as 
well as of HCl and pepsin. 

Of the somewhat difficult metJwds of examiidng the products of 
digestion we can here mention the two following : 

I. The transformation of the starches into erythro- and achroo- 
21 



322 SPECIAL DIAGNOSIS. 

dextrin can be qualitatively followed by means of dilute Lugol's solu- 
tion (iod. I part, iodid of potash 2 parts, aq. dest. 200 parts) : it colors 
starch blue ; erythro-dextrin, purple-red ; achroodextrin remains color- 
less or becomes yellow. A mixture of starch and dextrin with the 
first drops of the iodin solution becomes colorless, but upon further 
addition it becomes red and then blue. 

2. Peptone and propeptone in alkaline solution upon the addition 
of a solution of sulphate of copper give a beautiful purple color; 
albumin makes it a blue-violet; hence, on account of this similarity 
of colors, it is often extremely difficult to distinguish albumin from 
peptone, particularly if the stomach-fluid is turbid. 



By way of an appendix we give some methods which have only a 
hmited value for judging of disturbances of gastric digestion. The 
first two seek to supply a diagnostic need which indeed exists, but in 
our opinion is not fulfilled by this method. The effort is made to 
ascertain as exactly and simply as possible how fast and how com- 
pletely (if completely) the stomach empties its contents into the 
duodenum. 

1. TJie Salol Method of Ewald. — The peculiarity of salol that it 
splits up into salicylic acid and phenol only in the intestine, whereupon 
the appearance of salicylic acid in the urine is easily proved, has been 
employed by Ewald to determine the rapidity of the passage of food 
from the stomach into the intestine. SalicyHc acid is recognized in the 
urine after the addition of chlorid of iron by the violet reaction in the 
urine. In order to recognize the first traces we must make the test 
upon an ethereal extract [of the urine. (Compare what is said later 
regarding the Urine after the Administration of Medicines^ Ewald 
found that in health the first positive reaction took place a half to one 
hour after the salol had been taken ; when the process of transportation 
from the stomach has been interrupted he has seen it appear later. Con- 
trary to him, Huber and others find Ewald's method unreliable. They 
do not think that the time of the appearance of the reaction, but its 
shorter or longer duration, should be taken into account. In a healthy 
person, within twenty-six hours after taking a gram of salol, salicyHc 
acid ought to appear and then to disappear. In motor insufficiency of 
the stomach the reaction should last longer. Hence this method has 
been found unreliable. 

2. Klemperer' s Oil Method. — Klemperer has attempted a method 
which, from a purely technical standpoint, is seemingly very exact, 
but is decidedly impracticable. He introduces into the empty stomach 
100 grams of olive oil, and after a certain interval washes the stomach 
out. From healthy stomachs he found that in two hours 70 to 80 
grams of the oil had been discharged into the intestine, while in 
cases of catarrh of the stomach about half, and in one case of atrophy 
a quarter, of that amount had in the same time disappeared from the 
stomach. This method is less objectionable, because the oil is some- 
times not borne in the patient's stomach — it may even be rejected. 
But it is much more so because it does not represent any stimulus 






EXAMINATION OF THE DIGESTIVE APPARATUS. 323 

which corresponds to that which a meal of any kind exercises on 
the stomach. It has therefore been found unrehable by those who 
have tried it. 

The third method, given below, examines the capability of the 
stomach mucosa for absorption. It is not quite perfect, per se, and 
has lately lost in importance by the circumstance that the stomach, 
as unquestionable investigations have shown, absorbs different sub- 
stances in entirely different degrees, but upon the whole it possesses 
little importance for the absorption of the products of digestion, and 
none at all for the absorption of water. 

3. Penzoldfs Method for Examining Absorption in the Stomach. — 
Penzoldt gives 0.2 iodid of potassium in gelatin capsules, and then at 
once tests the saliva to see whether the capsule was close and free from 
iodid of potassium upon its outer surface. For this purpose we have 
the patient, moment by moment, spit upon a piece of filter-paper satu- 
rated with a solution of starch, upon which we place a trace of fuming 
nitric acid ; the appearance of the iodid in the saliva will be recognized 
by the red and blue coloration of the paper. In health the iodid will 
make its appearance, if it has been taken upon an empty stomach or 
three hours after eating, in from six and a half to eleven minutes ; if 
directly after a meal has been eaten, after twenty to forty-five minutes. 
In cases of dilatation, if taken upon a fasting stomach, its earliest appear- 
ance is after fifteen to thirty minutes. It also seems to be delayed in 
carcinoma, chronic catarrh, and in fevers. 

An improvement on this method, suggested by Sahli, consists of 
iodid of potash and fibrin contained in a small rubber pouch ; but, in 
our opinion and that of others, it furnishes no clearer results. 

Finally, on account of its historical interest, we mention here the 
method given by Leube, but superseded by his experimental meal. 
He introduced ice-water into the empty stomach and then aspirated it, 
in order to obtain for examination the gastric secretion pure — that is, 
diluted with water. 

Results of the Examination of Stomach-digestion, and their Sig- 
nificance. — Repetition of statements made before cannot be avoided 
here : 

1. If the stomach is found empty in the morning, there does not 
exist a severe motor disturbance, but slight motor disturbances are not 
excluded. If a considerable amount of food-substance remains, a severe 
motor disturbance exists — insufficiency in the second degree, simple 
insufficiency, pyloric stenosis. If the stomach contains hydrochloric- 
acid gastric juice, there is hypersecretion. Mucus indicates gastric 
catarrh. 

2. If at the time of the normal height of digestion of a test-meal 
there are strikingly few or no food-remnants at all, the evacuation of 
the stomach into the duodenum is accelerated : there exists an irritable 
condition which may have its origin within or without the stomach. 

Almost always there is much chyme of acid reaction. If it contains 
about 0.2 per cent, of hydrochloric acid, the gastric digestion is chemi- 
cally normal, and this is the case both after test-meals and after a test- 
breakfast. At the same time, the lactic-acid reaction may be positive ; 
much lactic acid, however, is not found. According to Martins and 



324 SPECIAL DIAGNOSIS. 

Liittke, lactic acid is even completely absent after a test-breakfast, and 
Uffelmann's reaction, if found, is said to be deceptive. 

Less than o.i per cent, of free hydrochloric acid must be considered 
as pathological. There then exists hypacidity (subacidity). In this 
condition abundant lactic acid is often found. 

If free hydrochloric acid is completely absent, we speak of anacidity. 
However, it must be noticed that here Sjoqvist's method, which also 
determines the loosely combined hydrochloric acid, almost always 
shows that there is secreted a greater, or sometimes also a very small, 
quantity of hydrochloric acid. In hydrochloric-acid anacidity there ex- 
ists simultaneously the most different degrees of increased fermentation, 
and even of putrefaction, with odor of butyric and acetic acids, forma- 
tion of gases, strong reaction of lactic acid, very high total acidity. 
Meat is always, starch also often, slightly or not changed at all. 

If we find more than 0.2 per cent, of free hydrochloric acid, it proves 
that there is hyperacidity. 

The utilization of these results for diagnosis must also always take 
into account the result of the other examinations of the stomach, and 
often enough also the patient's general condition. Thus, for instance, 
normal free hydrochloric acid with moderately retarded digestion and 
ectasia occurring after meals speaks for simple atony or slight and 
benign pyloric stenosis (scar from ulcer). 

Normal amount of free hydrochloric acid and normal duration of 
digestion with pronounced stomach complaints may not only exist in 
ulcer, but also in nervous dyspepsia. The deciding point is generally 
the manner and the time-relation of the complaints, and the finding of 
a circumscribed severe pain from pressure.^ 

Hypacidity exists in catarrh of the stomach, carcinomatous and, 
above all, non-carcinomatous, stenosis of the pylorus, and in ectasia, in 
carcinoma generally, in all possible cachexias and anemias, and, finally, 
in neuroses. In pulmonary tuberculosis, however, the percentage of 
hydrochloric acid differs in different cases, just as the general functional 
capacity of the stomach varies. In this disease it is therefore necessary 
in many cases to study more attentively the chemistry of gastric diges- 
tion. As regards the behavior of the stomach in other diseases of other 
organs, hydrochloric acid seems to be normally secreted in heart- 
diseases, unless there is catarrh in consequence of defective flow of 
blood (Einhorn). In subacute and chronic nephritis Biernacki has often 
found a considerable decrease of hydrochloric acid. In diabetes free 
hydrochloric acid is not infrequently absent permanently or for some 
time (Rosenstein). 

Hypacidity, and even anacidity, have very different significance 
according to the coincident condition of the motility of -the stomach. 
If a deficiency of hydrochloric acid is combined with stagnation, 
abnormal fermentations occur; if the chyme, however, not having been 
sufficiently prepared by hydrochloric acid and pepsin, is transported 
into the intestines at the right time or even earlier, before abnormal 
decompositions have developed, the intestines may vicariously take up 
the further digestion without disturbance, particularly when the food 
contains few micro-organisms, is tender, and well masticated. 

1 See p. 273. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 325 

However, Kast has found that if the hydrochloric acid is weakened 
in the stomach by an abundant supply of alkali, considerable quantities 
of ethyl sulphuric acid appear in the urine, from which it must be con- 
cluded that the processes of putrefaction in the intestines are increased. 
Kast refers this, probably correctly, to the circumstance that the anti- 
bacterial action of the gastric juice does not come into effect. But, at 
any rate, as has been proven by the works of v. Noorden, the nutrition 
cannot necessarily be injured, though the chemical function of the 
stomach be impeded, so long as its motive power is preserved. 

Anacidity, first of all, always suggests carcinoma — an empirical 
tenet which cannot be shaken. It is possible that the carcinomatous 
disturbance of metabolism is the cause of the defective secretion of 
hydrochloric acid (Fr. Miiller). In pyloric stenosis of doubtful nature, 
when there is a doubtful tumor at some other part of the stomach, the 
accompanying anacidity is of symptomatic value. On the other hand, 
sometimes in carcinoma there is hypacidity, and even normal free hydro- 
chloric acid in spite of ectasia ; hence in the latter case there probably 
may be excessive secretion of hydrochloric acid, while, on the other 
hand, individual cases of long standing ectasia from pyloric cicatrization 
may lead to anacidity (atrophy of the mucous membrane). In some 
cases of carcinoma with abundant secretion of hydrochloric acid there 
had previously existed an ulcer. 

Further, anacidity has been observed, and not only an actual absence 
of hydrochloric acid, but also the loosely combined acid, in the so- 
called atrophic gastric catarrh and in amyloid degeneration of the 
gastric mucous membrane. 

Hyperacidity exists in the majority of cases of ulcus rotundum [per- 
forating ulcer of the stomach], also in acute, and sometimes, though 
seldom, in chronic, gastric catarrh. It also occurs in nervous dyspepsia 
and general neuroses, both constant and periodic, and as nervous dys- 
pepsia in neurasthenia, as gastroxynsis acuta, or in migraine. Also 
the gastric crises of tabetic patients are sometimes accompanied by 
hyperacidity. Lastly, it has been observed in depressing psychoses. 

In many of these cases hyperacidity is connected with hypersecre- 
tion, and occasionally in ulcer and catarrh as well as in neuroses. 

Hypersecretion, both with and without increased hydrochloric acid, 
occurs independently in the gastric crises of tabes and in certain 
neuroses (hysteria, nervousness). It is sometimes also observed with 
gastric ulcer, also in individual cases of carcinoma, and in acute chronic 
catarrh. 

3. Increased amount of HCl at the height of digestion, shortening 
of the time (normal maximum of one hour) during which lactic acid is 
present, are signs of superacidity. Thus the period of digestion is 
shortened, or normal, or sometimes even prolonged. As evidence of 
disturbed amylolysis we have unchanged starch during the whole 
period of digestion. 

Superacidity is present in the majority of cases of ulcer, also in 
certain nervous dyspepsias (gastroxynsis, pyrosis hydrochlorica), lastly 
in acute and sometimes in chronic gastric catarrh. It is also observed 
in the forms of insanity accompanied by depression. 

Sometimes in chronic dyspepsia superacidity is combined with 



326 SPECIAL DIAGNOSIS. 

retarded evacuation — /. e. motor weakness. This may even increase 
till permanent dilatation takes place. Under some circumstances there 
then seems to occur a secondary injury to the mucosa, caused by the 
superacid gastric contents remaining so long in contact with it, which 
injury in turn causes a gradual change into subacidity. 

Vomiting and tlie Examination of the Vomited Material. 

The act of vomiting is produced by a sudden contraction of the 
stomach to which, in severe vomiting, is added an energetic co-operation 
of abdominal pressure by contraction of the diaphragm and the trans- 
verse abdominal muscles. The contraction of the stomach is restricted 
to the pyloric portion, the cardiac end remaining quiet : the cardia 
opens ^yhilst the pylorus closes tightly. From the not infrequent pres- 
ence of bile in the last portions that are vomited toward the end of a 
severe effort at vomiting, it seems that during the pauses of the attack 
of vomiting the pylorus does not entirely close. 

In this connection we do not include the vomiting, or rather the 
expulsion, of food from dilated parts of the esophagus when there is 
stenosis or diverticula.^ 

Vomiting may occur in a great variety of ways and in diseases 
which differ greatly in character. We suppose that the so-called 
vomiting-center is situated in the oblongata. This may be stimulated 
from the periphery, chiefly through the sensory portion of the vagus, 
and so give rise to reflex vomiting. Moreover, it rrtay be stimulated 
directly or by impressions from other portions of the brain (central 
vomiting). 

Children generally vomit easier than adults. There are also indi- 
vidual differences. Clinically, we distinguish — 

1 . Vomiting occasioned by reflex influences from the stomach. It 
occurs not only in all diseases of the stomach, but also in irritation 
of the mucous membrane of the stomach by different poisons, certain 
emetics, etc., and also by overloading the stomach. 

2. Reflex vomiting caused by otJier abdominal organs, as from the 
female sexual apparatus in menstruation, pregnancy, diseases of the 
sexual apparatus ; from inflammation of the peritoneum ; also, in renal 
and biliary colic, etc. 

Likewise, vomiting may be caused by irritation or tickling of the 
fauces. Probably here also belongs vomiting which occurs at the end 
of a severe fit of coughing, as in whooping-cough and phthisis. 

3. Central Vomiting. — It may result from various kinds of irrita- 
tion of the brain : as different evident diseases of the brain, especially 
tumors ; in the different forms of meningitis ; in neuroses, particularly 
hysteria ; and from uremia. Vomiting occurs also in the beginning of 
certain acute infectious diseases, as pneumonia, scarlet fever, small-pox, 
erysipelas [and remittent fever]. 

Vomiting is almost always accompanied by certain other phenom- 
ena — previous malaise, often severe sweating, quickening of the pulse ; 
exhaustion with the feeling of relief, but also evidences of collapse. 
In diseases of the brain it sometimes occurs without any preliminary 
indisposition, even quite suddenly and unexpectedly. 

^ .See Examination of the Esophagus. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 327 

As regards the time when the vomiting begins in diseases of the 
stomach, it often (not always) follows eating. Also in peritonitis 
vomiting is often excited by the taking of food ; but here also it takes 
place quite independently of this. The vomitus matiitinus of drunkards, 
as a rule, regularly occurs early in the morning, when the stomach is 
empty. Also in certain nervous dyspepsias there are apt to be attacks 
of vomiting when the stomach is empty. When there is severe vomit- 
ing without phenomena of stomach or other abdominal disturbances, 
we must take into consideration the other conditions named above — 
acute infectious diseases, disease of the brain, uremia, hysteria — accord- 
ing to the circumstances. 

The frequency of vomiting is extraordinarily variable, and is of 
little moment in diagnosis ; only it might be mentioned that in very 
marked dilatation of the stomach from pyloric stenosis vomiting occurs 
remarkably infrequently, but in most cases tolerably regularly, at inter- 
vals of several days, but then very profusely. 

There may be eructation in all the conditions in which vomiting 
occurs. It is observed especially in both slight and severe diseases of the 
stomach of all kinds. Sour eructation and pyrosis [heartburn, water- 
brash] may be dependent not only upon abnormal lactic-acid formation, 
but also upon superacidity (pyrosis hydrochlorica). In individual cases 
combustible gases have been observed (marsh gas and probably also 
other gases). There occur with nervous persons very distressing and 
entirely odorless eructations. 

The Vomit. — When we examine the vomit we notice the quan- 
tity, the macroscopical and microscopical appearances, the odor, and the 
reaction. 

The chemical examination can probably occasionally enable us to 
judge of the character of the stomach-digestion. This is especially 
the case in those diseases which we cannot include in a methodical 
investigation, as inclination to hemorrhage, etc.^ Of course we must 
consider the relation of the vomiting to the time of the last meal and 
of what the meal consisted. The points of view are to be taken from 
what has been said above regarding experimental digestion. Where 
there are macroscopical appearances of blood and coloring matter of 
bile we must further apply the chemical tests for these substances. 

The Quantity of Vomit. — Here we must consider the time and 
frequency of the vomiting, as well as the amount of food taken. When 
there is vomiting from an empty stomach, usually there is only a little 
mucus, seldom much mucus or saliva that has been swallowed {vomitus 
matutinus potatorum), or more or less pure gastric juice {liypersecre- 
tion). In acute infectious diseases, diseases of the brain, uremia, some- 
times scarcely anything at all is vomited. 

A vomiting which seems to result from the ingestion of food, but 
the amount of which considerably exceeds the quantity of food and 
drink last taken, is an almost mathematically sure proof of dilatation 
of the stomach. Here the contents of the stomach may accumulate 
for a number of days, and then be thrown off en masse to the amount 
of several liters. 

The Macroscopical Appearance. — This will naturally depend very 

1 See above. 



328 SPECIAL DIAGNOSIS. 

much upon the food taken. It was mentioned above, when speaking 
of the experiments with digestion, that under some circumstances we 
can form a conclusion regarding digestion by the comminution of the 
food. Some foods, as coffee, cocoa, red wine, huckleberries, etc., 
markedly color the vomit, and may sometimes give rise to mistake, 
if superficially examined, by causing one to think that there has 
been hematemesis (the laity being not infrequently thus deceived, and 
hence we must be very careful in accepting the anamnesis). When 
preparations of iron have been taken the vomit is black, but it is also 
sometimes black in acute lead-poisoning. Apart from the food from 
some prominent constituents (when the contents of the stomach are 
abnormal), we can make certain important distinctions in what is 
vomited, just as with the sputum. 

Watery^ watery-mucous, mucous vomit. The first and the second 
named may ordinarily have two very different meanings. In both 
cases we have a somewhat turbid fluid, resembhng saliva or fluid 
mucus, which is vomited from a fasting stomach. It has an alkaline 
reaction, and usually indicates chronic gastric catarrh. The fluid 
consists of mucus from the mucous membrane of the stomach and of 
saliva that has been swallowed. In this way the frequently men- 
tioned " water-brash " of drunkards {zwmitus matutinus potatorum) 
especially manifests itself in the early morning immediately after rising. 
Also such vomiting occurs (rare) in nervous dyspepsia. If the fluid 
smells sour and has an acid reaction, and if it shows the muriatic-acid 
reaction and power of digestion, then we have gastric juice secreted by 
the empty stomach — hypersecretion. This .gastric juice is often over- 
acid — Jiypersecretion with hyperacidity (over 0.3 per cent.). This 
occurs in certain kinds of nervous dyspepsia (gastroxynsis, gastroxia ; 
also hysteria ; tabes) ; but also in dyspepsia following healed ulcer and 
acute and chronic gastric catarrh. In these cases the quantity vomited 
may amount to several hundred grams. 

Mucous vomit. A special form of watery-mucous vomit is peculiar 
to Asiatic cholera. In this disease there is often vomited a great quan- 
tity of alkaline, stale-smelling fluid, like rice-water (very like the stools 
of cholera).^ The small flocks resembling rice are mucous flocks. It 
is not possible to separate mucous from watery-mucous vomit. Some- 
times a great quantity of mucus is observed in chronic catarrh of the 
stomach. 

Bilious vomit. As previously mentioned, bile may be mixed 
with every vomit, and this is especially apt to be the case in very 
severe efforts at vomiting, so that toward the end almost pure bile is 
ejected. The vomit looks yellowish-green or green, and smells decid- 
edly bilious. It exhibits the reaction of the coloring matter of the bile.^ 

A grass-green bilious vomit, occurring with tolerable uniformity 
with every act of vomiting, whether violent or not, is a not unimport- 
ant peculiarity of peritonitis and of marked obstruction of the bowels. 

Bloody vomit, vomiting of blood (hematemcsis\ Blood from the 
nose, throat, or esophagus may become mixed with the vomit in the 
act of vomiting. Small quantities i;i streaks are usually of no sig- 
nificance. Large hemorrhages from the esophagus, as in varices of 

^ See below. ^ See Urine. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 329 

the lower portion of the esophagus, and in cirrhosis of the liver, usually 
after it has run down into the stomach, cause severe hematemesis. 
Also blood from the nose, and even from the lungs, may reach the 
stomach and be vomited.^ We must be careful not to confound 
such an occurrence with hemorrhage of the stomach. In doubtful cases 
the anamnesis is of less value than the examination of the stomach, 
nose, and lungs.^ 

Small points of blood and streaks in the vomit, even if they come 
from the stomach, according to our experience, are moreover gener- 
ally without significance : that they are from the stomach is proved by 
the presence, not infrequently, of bloody suffusion of the mucous mem- 
brane of the stomach at the autopsy. Streaks of blood frequently 
recurring, whose source the autopsy proves to be the stomach, are not 
at all uncommon in cirrhosis of the liver. 

Bloody vomit, from liemorrhage of the stomacli, takes place in ulcer 
of the stomach, carcinoma ventriculi, portal engorgement from cir- 
rhosis of the liver, closure of the portal vein (rarely in general venous 
stasis), in severe lesions of the mucous membrane of the stomach by 
corrosive poisons, also in general hemorrhagic diathesis,^ in yellow 
fever, melaena neonatorum ; in the last-named cases there usually 
occurs simultaneous hemorrhage of the bowels. Very decided, and 
sometimes fatal, hematemesis is chiefly peculiar to ulcus ventriculi 
(also melaena). In carcinoma we notice very frequently repeated, but 
always moderate, hemorrhages. Moreover, in all these conditions the 
vomiting of blood may be entirely wanting, either because there is no 
escape of blood into the stomach or because the blood is not vomited. 

When we suspect hemorrhage of the stomach, which is not vomited, 
we are to examine the stools.'' Sometimes in ulcer of the stomach the 
patient becomes suddenly pale, may collapse, or may even die from a 
hemorrhage of the stomach, without there being any vomiting of blood. 
In order to observe exactly an ulceration of the stomach, it is particu- 
larly necessary to observe uninterruptedly the stools. 

Pure blood is seldom vomited, unless there is a great quantity of it, 
or it is vomited directly after or during the hemorrhage. Moreover, 
it is never of so clear an arterial color as in hemorrhage of the lungs. 
The blood is almost always more or less changed by the gastric juice : 
it is very dark, black-brown, and has an acid reaction. If it has been 
in the stomach for some time, as is quite often the case in carcinoma 
with dilatation, because the hemorrhages are usually small and there 
are long pauses between the hemorrhages, under the influence of the 
acids, by the breaking-up of the red corpuscles and the hemoglobin 
and the appearance of hematin, it becomes coffee-brown and of the 
consistence of coffee-grounds. Then, if abundant, it is easy, with 
some experience, and provided there is sufficient quantity, to recognize 
it ; yet it is easy to confound it with other substances, as coffee, cocoa, 
etc.^ For this reason, and because here the microscope is deceptive, 
it is preferable in this case always to make a special test of the blood. 

1 See p. 66. 

2 See pp. 145, 146 for further particulars regarding the distinction of hemorrhage of the 
lungs from that of the stomach. 

3 See Cutaneous Hemorrhages. * See this. ^ See above. 



330 



SPECIAL DIAGNOSIS, 




Testing the Blood. — i. Very correctly, the hemin test is generally 
employed, because it is certain and distinct. The following is the best 

way to make it : Some of the 
coffee-grounds material is filtered; 
a little of this is to be evaporated 
in a watch-glass. Scrape off some 
of the dried material, mix it with 
a trace of finely-pulverized salt, 
place the dried mixture upon an 
object-glass, cover it with a glass 
cover, and allow one or two drops 
of o-lacial acetic acid to flow under 

o 

the cover-glass ; then the acetic 
acid is again evaporated very 
slowly, and, after it is thoroughly 
dry, one or two drops of distilled 
water are allowed to flow under to 
dissolve any crystals of salt that 
Fig. io9.-Crystais of hemin. Zeiss's may be present. Under the micro- 

apochromatic lens No. 8, eye-piece No. 8, scOpC there can be Seen crystals 
camera lucida. Magnified about 300 diam- ^^ j^^^j^ (hydrochloratc of hema- 

tin) in coffee-brown or reddish- 
brown crystals in rhombic plates (see Fig. 109), which must be con- 
siderably magnified, as the crystals are very small. 

2. The following method (an adaptation to the vomit of Heller's test 
for blood-coloring material in the urine, which see) leads to a result 
more quickly : We place some of the filtered stomach-fluid in a 
reagent-glass with a like quantity of normal urine, make it strongly 
alkaline with liquor potassa^, and heat it. The urine-phosphates are 
precipitated, and carry with them the coloring-material of the blood, 
and when blood is present we have a cloudy, flocculent, reddish-brown 
deposit. 

Vomiting of Pus. — Pus as a macroscopically visible constituent of 
the vomit is somewhat unusual, and is only observed in isolated cases 
of phlegmonous gastritis or of abscess of a neighboring organ breaking 
into the stomach. Probably it can then only be observed when it 
pours into the stomach in such quantities and so quickly that it makes 
the contents of the stomach alkaline, for only thus will it avoid imme- 
diate digestion. Regarding separate white corpuscles, see below. 

Fecal Vomiti^ig {Misej^ere, Iletis). — In this condition either there are 
considerable quantities vomited which do not look distinctly feculent, 
probably coming rather from the stomach or the upper portion of the 
small intestine, and the fecal addition is betrayed by its odor, or there 
are distinctly fecal masses, even balls of excrement. This kind of vomit 
occurs in severe diffuse peritonitis and in serious occlusion of the 
bowels.^ It indicates an extremely serious and, in most cases, fatal 
condition, yet it does not by any means have the absolutely fatal 
significance which was formerly ascribed to it. 

As visible admixtures which can be seen with the naked eye are 
still to be mentioned — 

1 See Inspection and Palpation of the Abdomen. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 



11"^ 



Round worms, which come from the small intestine, probably 
brought into the stomach by the first efforts at vomiting, and are 
afterward seen in the material vomited. Their appearance is startling, 
but in itself has no significance. Also : 

Membranous rags of echinococcus in case one should break into the 
stomach from the liver or spleen. In these cases the microscope some- 
times shows the scolices and hooks of the parasite.^ 

Moreover, in individual cases there are found in the vomit also 
oxyuris, anchylostomae, trichinae.^ 

Microscopical Examination. — This is of very little independent 
value in determining the processes of digestion. In vomiting which 
takes place during digestion we of course expect to find portions of 
food in very varying conditions, according to the time the vomiting 
occurs. 

Starch-grains in considerable quantity for the time when the amyl- 
olytic digestive period ought to be past indicate incomplete amylolysis, 
as is almost always produced by hyperacidity (in consequence of the 
too early appearance of free muriatic acid). 

Mucous corpuscles are found in watery and mucous vomit ; epithe- 
lium from the mouth, throat, esophagus, also sometimes from the 
stomach, is observed ; unchanged red blood-corpuscles are very rare ; 
in hemorrhage of the stomach the microscope generally is useless, 
because the red blood-corpuscles are broken up. Also, it is rare to 
find white blood-corpuscles that are well preserved. 







Fig. iio. — Vomited material (v. Jaksch). 

a, Muscular fiber ; b, white blood-corpuscles ; c, c' , c" , flat and cylindrical epithelium ; d, starch-corpus- 
cles ; e fat-globules; f, sarcina ventriculi ; g, yeast-ferment ; h, z, cocci and bacilli (those near h were once 
tound by v. Jaksch m a case of ileus, hence arising from the intestine) ; k, fat-needles, connective tissue • / 
vegetable cells. ' 

Sarcina ventriculi (schizomycetes) and torula cerevisice (yeast-fungus) 
are not entirely without value as indications that the stomach retains 
its contents for a long time, as, especially, in dilatation. 

Of the two fungi, the sarcina is the more important. If it is not 
1 See Fig. 50, p. 158. .2 See these under Stool. 



332 SPECIAL DIAGNOSIS. 

macerated or deformed by pressure with the covering-glass it is gener- 
ally easily recognized, when strongly magnified, by its peculiar resem- 
blance to a bail wrapped with a string crossing at right angles. It is 
stained a reddish-brown by a weak solution of iodin or iodid of potas- 
sium. 

Torulas of different kinds and sizes (the latter very much like a 
small white blood-corpuscle, generally smaller) are easily distinguished 
as small bodies strung along together, sharply defined, which refract 
the light and are ^%^- or elliptical-shaped. Isolated ones are observed 
in the contents of the stomach with normal digestion. When the 
quantity is considerable it shows that it has been a long time in the 
stomach, whose contents have undergone alcoholic fermentation. 

Other different kinds of bacilli and cocci, which have only recently 
been carefully studied, are found in the vomit, but as yet they have no 
diagnostic value. 

Also, there are found in the vomit aphthae (probably originating in 
the esophagus),^ and favus fungus, achorion Schonleinii. 

Reaction of the Vomit. — This is usually acid from muriatic or 
organic acids.^ It may be alkaline when a considerable quantity of 
blood is vomited, as in water-brash, the watery vomit of Asiatic cholera ; 
also, rarely, in putrid vomiting, as in ulcerating cancer of the stomach, 
and in the vomiting of kidney-disease.''^ Moreover, " esophagus-vomit- 
ing " manifests itself by being always alkaline.* 

Odor of the Vomit. — In many respects this is very important. Thus, 
particularly, the presence of fatty acids is recognized with great certainty 
by their characteristic pungent odor. 

The odor is very important in many poisons, as with phosphorus 
(odor of garlic), bitter almonds, or nitro-benzole (odor of bitter almonds), 
ammonia, carbolic acid, etc. 

There is fecal odor with ileus, cadaveric odor in ulcerating carcinoma, 
also in fresh hemorrhage of the stomach. 

The odor is ammoniacal in nephritic patients, especially when there 
is uremia. It is thought to result from the separation of urea by the 
mucous membrane of the stomach, by the urea in the stomach chang- 
ing into carbonate of ammonia. 

A penetrating aromatic odor like prunes was observed a short time 
ago by Eichhorst in vomited matter which contained echinococcus 
membranes. This same odor was noticed by him in the sputum when 
an echinococcus had ruptured into the air-passages.^ 

Examination of the Feces. 

As in examining the contents of the stomach, the inquiring physician 
must pursue his task from two points of view : 

On the one hand, from the character of the intestinal discharges, he 
is to draw a conclusion as to the intestinal digestion and any possible 
disturbances of it from the abnormal chemical changes, and also an 
opinion regarding the present disease. On the other hand, he is to 
form a diagnosis directly from the occurrence of certain products of 

^ See above. ^ See above, Examination of Digestion. ^ See below, under Odor. 
"* See under Examination of Esophagus. ^ Compare p. 147. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 333 

disease, or even of substances generated by disease, as intestinal para- 
sites or micro-organisms found in the stools. Unfortunately, an ex- 
planation from the point of view first mentioned is difficult for several 
reasons : first, because we have to do with the last step of an extremely 
complicated process, and then in many respects we do not sufficiently 
understand this process itself or its pathological variations. With 
reference to the other point, and especially regarding organic exciting 
causes of disease, we have only a few sure principles, part of which are 
old and part have only recently been acquired. 

We have to consider — 

The intestinal discharges, with reference to their frequency and their 
possible, usually subjective, accompanying symptoms. 

The more particular examination of the stools: quantity, consist- 
ence, or form, color, odor. In addition, there are the admixtures 
which are visible by the naked eye and those to be seen only by the 
aid of the microscope. 

As yet, in our opinion, it is not possible to form an unimpeachable 
estimate of the intestinal digestion by the character of the intestinal 
secretion. It is well known that sometimes (especially by evacuating the 
fasting stomach) there enters into the stomach a fluid mixed with bile 
which is to be regarded as a mixture of pancreatic and intestinal fluids, 
since with an alkaline reaction it dio;ests albumin, starch is changed 
into dextrin and maltose, and fat is split up. But this occasional occur- 
rence has been very little employed for consecutive examinations. 
Boas recently, in a series of cases of habitual vomiting, by means of 
a stomach-tube, succeeded in obtaining a juice which he, as it seems to 
us, correctly regards as intestinal juice. However, we have not been 
able to convince ourselves that the results which this author has had 
in his cHnical experimental examinations furnish a distinct picture of 
the processes in the uppermost part of the small intestines. They 
have, therefore, as yet no value for the purposes of diagnosis. 

Intestinal Discharges. — In health their frequency varies individ- 
ually very much. Ordinarily, at all ages, excepting nursing children, 
who have three or four movements a day, there is one stool in twenty- 
four hours, but many persons regularly have a movement twice in the 
twenty-four hours, while others only have one in two or three days, or 
even at longer intervals, without experiencing any inconvenience [or 
disorder]. But in scarcely any other way do physiology and path- 
ology so much encroach upon each other's limits as with reference to 
the frequency of the intestinal discharges, for sometimes a movement 
even once in two days may be troublesome, and the physiological 
habitual constipation in many cases cannot in any way be distinguished 
from the pathological condition. 

Constipation, or, better, pathological constipation, is called obstipa- 
tion ; the expression obstruction (severe obstruction) is often inten- 
tionally used for constipation in a serious sense. The opposite to this 
condition is looseness, diarrhea. 

The frequency of the discharges is directly connected with the 
quantity of food taken ; hence a person who is fasting is always con- 
stipated. This point must often be thought of The character of the 
food, too, has an influence upon the frequency of the discharges and 



334 SPECIAL DIAGNOSIS. 

Upon the passage of food through the intestinal canal.^ Thus, rapid 
peristalsis causes diarrhea — slow peristalsis, obstipation. Hence any 
mechanical obstruction in the alimentary canal brings on constipation. 

DiarrJica is the most important sign of intestinal catarrh. This is 
brought about by errors of diet, by cold, by infectious causes, as the 
intestinal catarrh of typhus, dysenteric inflammation of the large intes- 
tine, and also many intestinal catarrhs which were formerly referred to 
the cause first mentioned. In this condition the stools are always 
thin ; ^ their frequency may be increased, even to occurring hourly or 
yet oftener. 

Moreover, medicines or poisons may increase the peristalsis alone 
or intestinal catarrh, and thus result in diarrhea. 

In all these cases the increased peristalsis increases the fluidity of 
the intestinal contents, even causing effusion from the intestinal wall 
into the intestinal cavity (cholera), until we have the condition of diar- 
rhea, regarding which, see below. 

Obstipation may be a disease which is relatively harmless, although 
very troublesome : habitual obstipation. But it is of much greater diag- 
nostic significance, however, as an early sign of peritonitis from paralysis 
of the intestine. Of still greater importance is severe obstruction in all 
forms of stenosis of the intestine, as fecal accumulation, particularly in 
the cecum ; strangulation, invagination, intussusception of the intestine ; 
new formations, scars in the intestinal wall, compressing tumors exter- 
nal to the intestine ; constrictions, bends produced by peritoneal exuda- 
tions. In many cases of chronic intestinal occlusion, as in chronic 
peritonitis, constipation alternates with diarrhea. 

But the condition of obstipation or diarrhea is still more affected by 
a possible increased or diminished abstraction of fluid from the intestinal 
contents : the more fluid there is, the quicker it passes through the 
bowel. Now, if the intestinal contents, as a result of prolonged reten- 
tion, part with much fluid when there is slow peristalsis, they become dry 
and hard, hence are carried forward with difficulty. If the peristalsis 
is quicker, the contrary exists. The effect of slow or quick peristalsis 
is felt in the transit [of the intestinal contents], causing either obstipa- 
tion or diarrhea. This is the explanation of the fact that usually obsti- 
pation and firm stools, and diarrhea and loose stools, coexist. 

The severest diarrhea occurs in cholera Asiatica, because in this dis- 
ease there is great effusion of fluid from the intestinal wall into the 
lumen of the intestine. 

1. It is to be understood that an ordinary constipation and severe 
obstruction are to be sharply distinguished from each other, for a quite 
ordinary obstipation may be very obstinate. Here the decision is made 
by considering other phenomena, as vomiting, pain, and particularly by 
examining the abdomen. This can never be omitted in any sudden 
attack of obstipation, special attention being given to the hernial orifices 
and the cecum. 

2. Persons who eat little or nothing, whom many things either 
strangle (stenosis of the esophagus) or cause vomiting, as in diseases 
of the stomach, but especially pyloric stenosis, in which case there 
is infrequent but copious vomiting at a time, cannot have frequent 

^ See under Quantity. ^ See the second section below, and Consistence of the Stools. 



I 



EXAMINATION OF THE DIGESTIVE APPARATUS. 335 

stools ; hence they must be obstipated. Such cases are easily over- 
looked, particularly if the patients complain a good deal of obstipation. 

The special peculiarities which precede the examination of the bowels 
are of diagnostic importance : 

Pain with the Stools. — There will be pain at the anus or at the 
lower portion of the abdomen in all kinds of inflammatory affections of 
the anus, the rectum, or their neighborhood. We have severest pain 
when the lower portion of the rectum is compressed by a large inflam- 
matory (purulent) exudation, especially in the exudation of peri- and 
parametritis ; also in fissure of the anus and abscesses from periproctitis.^ 
Likewise in carcinomatous, syphilitic, gonorrheal stenosis of the rectum, 
but also in the usually harmless Jicmorrhoids, the pain at stool is char- 
acteristic. Sometimes in all these conditions, and particularly in all 
inflammations of the large intestine, but most pronounced in dysentery, 
there is usually painful straining at stool, and pain after it — tenesmus. 
Whenever there is pain at stool there must be a careful inspection of 
the anus and palpation of the rectum. 

Involuntary discharges of the bowels, incontinentia alvi, are most 
frequently dependent upon the cloudiness of intelligence which accom- 
panies any severe disease ; but they may result from paralysis, particu- 
larly in diseases oi the spinal cord. When the stools are thin, incon- 
tinence occurs with less loss of inteUigence than if they are firm. Slight 
incontinence manifests itself sometimes by the fact that the patient must 
hasten to go to stool as soon as he has the impulse. Incontinentia is 
opposed to retentio ahi as regards its neurotic origin.^ 

Physical and Chemical Peculiarities of the Feces. — Amount. 
— Assuming an unobstructed passage, the amount of the stools is deter- 
mined by the quantity and quality of the food taken. In the latter 
respect it depends upon how much of the food is digested and taken 
up ; hence all vegetable foods make copious stools. 

Also, the quantity of the stools is increased in diarrhea, because too 
little of the fluid portion of the intestinal contents is taken up. The 
greatest increase occurs in cholera from the eflusion of quantities of 
fluid into the intestine. 

Enormous quantities of firm, solid stools may be passed after pro- 
longed obstipation or serious obstruction. 

We may form an estimate of the resorption of food from the amount 
of the stools or of their weight if we know how much of resorbable 
substances the food taken contains, and if we can decide that a par- 
ticular stool comes from the food taken within the period of observa- 
tion, by the admixture of substances which give a distinctive color. 
However, we neglect the addition made to the feces during digestion 
from the digestive juices : on the one side, there is a too rapid move- 
ment of the food along the alimentary canal, and, on the other, dis- 
turbance of the resorption of the food. We learn from the recent 
investigations of F. Miiller and Abelmann that in mild enteritis and in 
mild amyloid degeneration only the fat, but in severe cases of disease 
of the mucous membrane all the nutritive material, is poorly resorbed ; 
further, that if there is a deficiency of pancreatic juice fats are split up, but 
(with the exception of milk) are not absorbed, and only about half of 
1 See Surgery. ^ See Examination of the Nervons System. 



336 SPECIAL DIAGNOSIS. 

the albuminous substances are absorbed ; deficiency of bile and tubercu- 
losis of the lymphatic glands disturb the absorption of fat ; finally, that 
absorption is only slightly disturbed by accumulation in the intestinal 
canal. 

Consistence or Form of the Stool. — Normally, it is firm or mushy. 
The fact has already been stated, and the reason given, why in diarrhea 
the stool is more or less thin or like thin soup. The stool may really 
be watery, as in cholera Asiatica, but also in all severe acute cases of 
enteritis, also in dysentery. The dried fecal balls which are passed 
with or after obstipation are very hard. 

The/<?r;;2 of firm feces does not have any independent value. Espec- 
ially the stool, which is Hke the stool of sheep (small, hard balls about 
the size of a cherry), is not characteristic of stenosis of the rectum, 
because it also occurs in ordinary constipation. Band-like flat scybala 
rather indicate stenosis, more especially compression of the rectum 
antero-posteriorly. 

Here may be mentioned the arrangement in layers of the thin and 
the mushy stools which not infrequently are met with. In these the 
firm portions settle so that the upper part of the stool consists of a 
clear watery layer. This is the kind of stool we have in typhus ab- 
dominalis [typhoid fever], but we also have it in other thin stools, and 
it is very commonly a result of the admixture of urine. 

Odor of the Stools. — The variations from the normal fecal odor not 
infrequently have distinct diagnostic value. In nursing children a 
slightly sour odor is normat. 

The alcoholic stool is offensive, but does not always really have a 
foul odor. An odor like fatty acids (and acid reaction from acid fer- 
mentation) is peculiar to the slight forms of infantile diarrhea. A 
decidedly foul smell (putrid albumin, " alkaline fermentation ") belongs 
to severe forms of this disease. The stools of cholera and dysentery 
often smell flat, like semen (cadaverin, Brieger). Cadaverous, foul, 
stinking stools characterize gangrenous dysentery, carcinomatous or 
syphilitic ulceration of the rectum. When blood or pus is mixed with 
the stool in considerable quantities, the fecal odor may be masked and 
replaced by a mild, stale odor. Often the stool is ammoniacal from 
admixture with urine which has decomposed. 

Reaction of the Stools. — Only in children, particularly nurslings 
(in whom it is normally slightly acid), is the reaction diagnostic and 
gives important indications for treatment. Decidedly acid reaction is 
observed in acid fermentation in the intestinal canal ; alkaline reaction 
in alkaline fermentation, with putrid albumin. In both conditions there 
is intestinal catarrh. 

Color, Constituents, Admixtures of the Stools (so far as they can 
be recognized by the naked eye). — The normal color of the stools 
varies from bright- to blackish-brown. It is in part due to the addition 
of bile (that is, products of decomposition of the coloring matter of the 
bile, particularly hydrobilirubin) and partly to the food. By the latter 
the stool may be unusually colored, as by huckleberries, which color it 
black, and may be confounded with blood. 

In the normal stool portions of food can be recognized with the 
naked eye if things that cannot be digested — like cherry-stones, par- 



» 



EXAMINATION OF THE DIGESTIVE APPARATUS. 337 

tides of wood, etc. — have been swallowed. We also see grape-seeds, 
the skill of many kinds of fruits, etc. Large fibers of connective tissue, 
undigested portions of grains, mushrooms, etc., may sometimes be met 
with in the stools if the patient has eaten rapidly or has swallowed his 
food in quantities. With the naked eye we can see fibers and pieces 
of undigested substances (the old designation for which was lientery), 
like portions of muscle, flocks of casein, in the stools of children, 
sometimes somewhat friable, perhaps slimy, or even portions of starch. 
All of these indicate disturbance of digestion in the small intestine, or 
also in the stomach, as is seen in intestinal catarrh or catarrh of the 
stomach, or in the dyspepsia of fever, with increased peristalsis. 

In the rare condition of communication between the stomach and 
colon (perforating ulcer of the stomach) we find the coarsest admixture 
of digestible portions of food in the stool. 

Occasionally, extraordinary forms of remains of vegetables (orange- 
like, etc.) have given rise to mistake. With children, hysterical per- 
sons, and imbeciles we must be prepared for all sorts of preposterous 
foreign bodies in the stools. 

The stools of nurslings and of adults who live upon milk illustrate 
the appearance of the stool when colored only by bile-pigment. Firm 
stools are generally darker than thin ones, because more concentrated. 
In severe diarrhea, but especially in cholera, dysentery, also severe 
enteritis, after the first evacuations have swept out the intestinal con- 
tents the stools always become brighter, afterward grayish-white and 
watery, or, in dysentery, colored by blood, etc.^ 

When there is diminished floiv of bile into the intestine, as occurs 
in hepatogenous icterus, the stools are lighter. If the bile is cut off, 
they are grayish-white, clayey, and faintly glistening. This is due not 
alone to the want of the transformation of the bile-pigment, but also, it 
would seem, chiefly to the large amount of fat in the so-called acholic 
stools. The increased amount of fat, in turn, shows diminished diges- 
tion of the fat, due to the deficiency of bile. 

We designate as bilious stools those which contain the coloring- 
matter of the bile unchanged. A quick passage of the contents of 
the intestine and profuse diarrhea always bring about this kind of 
stool. We see it most frequently in acute intestinal catarrh, especially 
in children ; perhaps there is here also an increased effusion of bile. 
The bilious stool is bright-yellow, green-yellow, or green, and has the 
reaction of the coloring-matter of the bile. We filter it and treat the 
filtrate as we do when testing for bile in the urine.^ 

Mucous Stools. — When mucus can be distinctly recognized in the 
evacuations of the bowels, it always indicates catarrh of the mucous 
membrane of the intestine, and hence something pathological, though 
in many cases the disturbance in the intestines may be regarded as 
without significance. There are unnoticeable transitions from the 
normal secretion of mucus by the intestine to a decided stimulation by 
chemical or mechanical irritation, even to a true enteritis. Nothnagel 
considers that small, visible particles of mucus interspersed in firm 
stools belong to a normal condition. 

Larger masses of mucus in the form of more or less thick shreds 

1 See below. 2 ggg \}c{\%, 

22 



338 SPECIAL DIAGNOSIS. 

always indicate with greater probability a catarrh of the large intestine. 
Certain small, roundish particles of mucus, like sago-granules, are said 
to come usually from this portion of the intestine. Catarrh of the large 
intestine, then, can be definitely diagnosed from the stools if firm fecal 
balls are passed which are covered with mucus. Sometimes we find 
spread over the scybala a layer of thick, tough mucus ; this occurs, 
however, only in chronic catarrh of the large intestine. An abundant 
admixture of mucus in thin stools occurs, especially in acute intes- 
tinal catarrh, if the large intestine is also affected, and in catarrhal 
dysentery. 

We designate as intestinal infarction cylindrical tubes which consist 
entirely of mucus (or partly of fibrin) and which form casts of the 
large intestine. In rare cases they occur in chronic catarrh of the 
large intestine, and are usually passed with great pain (mucous coHc). 

If there are fine and equal portions of mucus in soHd fecal balls, 
we then think of catarrh of the small intestine. But, also, mucus 
occurring in thin stools may have its origin in the small intestine. 
Then it is usually finely divided and is soft. In cholera Asiatica (also 
in cholera morbus) the stools are watery and contain particles of mucus 
which look like boiled rice {ince-water stools). 

Nothnagel utters a warning against regarding all small, sHmy-look- 
ing particles in the stools as mucus. They may also come from the 
food. 

Watery Stools. — To these we have already referred repeatedly. 
They occur in severe acute intestinal catarrh, in dysentery, and in 
cholera Asiatica, and express profuse diarrhea, by which the intestinal 
contents are completely expelled. Even bile or its transition products 
are not usually found in watery stools. 

Fatty Stool. — This is usually recognized by its slightly glistening 
and its greasy look. When there is much fat, the stool is clayey- 
looking or whitish, even when the bile is not cut off from the intes- 
tine. When the stool contains considerable fat, moreover, it has the 
pecuharity of becoming softer and more glistening with the elevation 
of the temperature of the body. (For further regarding fatty stool 
and its occurrence, see under Microscopical Examination.) 

Bloody Stools. — These have an extremely variable appearance, de- 
pendent upon the more or less change in the blood, and whether it is 
not at all or is intimately mixed with the feces. 

When firm scybala are covered with blood, they indicate hemor- 
rhage of the rectum or large intestine. If the blood does not look 
at all changed, it is from the rectum or anus. When there is an 
admixture of blood with thin stools, if the blood retains its color and 
is not intimately mixed with feces, mucus, or pus, it points with 
tolerable certainty to the large intestine or anus. However, there may 
be intimate mixture of blood even in hemorrhage from the large 
intestine and in watery stools, as in meat-juice stools in dysentery and 
severe catarrh of the large intestine in children. 

'Hemorrhage of the large intestine occurs most frequently with 
hemorrhoids in the lower portion of the rectum, carcinomatous ulcera- 
tion, again chiefly from the rectum, and in other ulcerations of the 
large intestine of any kind, as in dysentery. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 339 

When the blood is intimately mixed with the feces, it indicates 
hemorrhage from the small intestine or from the stomach. Besides, in 
this case the blood is usually more or less changed, brownish-red, even 
deep-black, the color of tar, from the breaking up of the red corpuscles 
and of hemoglobin (formation of sulphate of iron ?). 

The degree of change which the blood undergoes depends upon the 
length of time it has been in the intestinal canal and the way in which 
it is mixed with the feces. There is the least change, the blood some- 
times remaining red, with preservation of the red corpuscles, when a 
large quantity of blood from the lower part of the ileum passes quickly 
into the colon because of existing diarrhea. This happens with the 
profuse hemorrhage of the bowels in typhus abdominalis [typhoid 
fever]. Blood which comes from the stomach and duodenum (in ulcer 
of the stomach, idcus dicodenale) becomes as black as tar before it is 
evacuated, because of its slow transit and the usual absence of diarrhea. 
Moreover, with gastric hemorrhage the blood in the stool may have 
the appearance of coffee-grounds.^ 

In most cases in order to prove the existence of blood it does not 
suffice merely to examine with the naked eye. Then we employ the 
microscope to make out the red blood-corpuscles, and if they are 
broken up, then it is necessary to test for hemin? 

1. We have already repeatedly spoken of the importance of giving 
continued attention to the stools whenever there is a suspicion of 
hemorrhage in the alimentary canal. This obtains particularly with 
ulcer of the stomach or duodenum. 

2. It is evident that any blood which reaches the stomach, having 
its origin in the esophagus or coming from farther up and being swal- 
lowed, may appear in the stools.^ 

Purulent Stools. — A considerable quantity of pure pus is not so 
very rare, happening as a sign of a rupture somewhere of a collection 
of pus (generally of a parametric exudate) into the intestines, espe- 
cially the rectum. Therefore, whenever there is a febrile affection of 
the abdomen, where the formation of the pus is either made out or at 
least is thought to be possible, we ought always, but especially if there 
has been a sudden decline of the fever, carefully examine the stools 
as well as the urine.* Moreover, dysenteric, catarrhal, syphilitic, and 
carcinomatous ulcerations of the large intestine produce some, or possi- 
bly considerable, accumulation of pus, according to their extent ; like- 
wise, periproctitic abscesses. 

While larger and especially flocky admixtures of pus are easily 
detected by the naked eye, finer admixtures of pus may escape it, 
especially when the stools are thin and of a light-yellow color. It is 
therefore advisable when there is a suspicion of pus to use the micro- 
scope. 

Gall-Stones ; Enteroliths. — The former either come from the gall- 
bladder or the intrahepatic gall-passages (intrahepatic stones, much 
smaller than the others, rare) through the ductus choledochus, and, as 
they come into the intestine, often produce severe colic and jaundice. 
Whenever there is abdominal coHc, particularly if it is connected with 

1 See alDove, p. 329. ^ See above, p. 330. 

3 See Examination of the Nose, Expectoration, Esophagus. * See this. 



340 SPECIAL DIAGNOSIS. 

jaundice, and generally whenever there is jaundice, we must look out 
for gall-stones in the stools. In rare cases, if there is suppuration of 
the gall-bladder, they come from the gall-bladder, there being adhesion 
with the colon, into which they break and thus directly reach the 
intestine. 

When we are looking for gall-stones the stool must be passed 
through a sieve. If it is formed or mushy, it must be broken up by 
pouring a stream of water upon it. The gall-stones are generally very 
easily recognized by their shining appearance, smooth surface, and 
irregular, many-angled (facets) form. Sm.all, especially intrahepatic, 
stones may not have facets and be more crumbling. They consist 
chiefly of cholesterin, and also contain coloring-matter of the bile. 

The observations of Fiirbringer show that when people have eaten 
pears, particularly those w^hich contain many concretions, these con- 
cretions, appearing in great abundance in the stools, may be mistaken 
for gall-stones. They are white-yellow, loam-colored to red-brown 
formations, of the size of a grain of sand to that of a pea, and some- 
times still larger. They give neither the reaction of cholesterin, nor, if 
cleansed from feces, of bilirubin, and consist microscopically of stone- 
cells. It is conceivable that they might ^\w^ rise to an erroneous 
diagnosis of gall-stone colic if found in the stools of a patient with 
icterus or complaining of colicky pains. 

Methods of Chemical Examination of Gall-stones. — (a) Test for Choles- 
terin. — Pulverize ; dissolve in hot alcohol ; filter ; allow one drop of the 
filtrate to fall on a glass slide. When dry the characteristic plates of 
cholesterin are seen.^ 

ip) Test for BiliriLbm. — The remains on the filter are to be slightly 
acidulated with hydrochloric acid, mixed with chloroform with warmth, 
and allowed to stand a moment. The decanted chloroform forms with 
nitric acid a beautiful green. 

Enterolitlis are rare. They usually come from the vermiform 
appendix, and their center commonly consists of solid, undigested 
portions of food, as a cherry-stone, around which have been deposited 
some lime or magnesium salts. 

Portions of Tissue from the Intestinal Canal. — In very rare cases, 
when there is invagination of the intestine, the whole of the portion 
that is turned in sloughs off, the intestine forming new adhesions, 
and thus life is preserved. This entire piece may appear in the stool. 
Shreds of mucous membrane from the large intestine in dysentery, 
portions of tissue of carcinoma, or other new formations may appear 
in the stools. 

Animal Parasites. 

In what follows it will be shown that some of the animal parasites 
that exist in the human alimentary canal have no pathological signif- 
icance ; others, on the other hand, are very important factors as exciters 
of disease. The examination for these latter or for their eggs cannot 
be made too frequently or too carefully. An examination of the stools 
for parasites must be undertaken not alone w^hen there are complaints 
of symptoms which directly indicate intestinal parasites, or in general 

1 See p. 156. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 



341 



when there are evidences of intestinal catarrh, but in any case of anemia 
— when there is any general nervous depression — in certain other phe- 
nomena of the nervous system ^ if the cause of the particular complaint 
does not appear to be clear. The cases are numberless where, after 
long fruitless search elsewhere, the discovery of a joint of a tapeworm, 
for instance, leads to the correct apprehension and treatment of the 
patient. 

In order not to separate what belongs together, we collect here all 
that is to be said regarding the occurrence of intestinal animal parasites 
and their eggs in the stools, whether in the examination we employ the 
naked eye, the simple or the compound microscope. 

Tape-worm (Cestodes). — Its habitat is exclusively the small intes- 
tine. It gives rise to very great pathological disturbances (intestinal 
catarrh, anemia, nervous manifestations of varying severity). It con- 
sists of a very small head and neck and a ribbon of flat joints (proglot- 
tides) several meters long, which constantly push off at the end of the 
worm and grow again from above. It clings to the wall of the intestine 
by its head. 

It can be recognized by a single joint, which can easily be seen with 
the naked eye, or by the presence of eggs in the stools (microscopical 
examination). 

I. Taenia Solium. — This is 2 or 3 m. long. Its head is the size 
of the head of a pin, ghstening gray ; the rest of the worm is white or 
yellowish-white. Upon the head are four pigmented sucking-cups (to 
be seen with a simple microscope), which surround a crown of chitin- 
hooks, ** crown of hooks." The ripe proglottides — that is, those on the 
lower end of the worm — are about 10 mm, long, 5 or 6 mm. broad, and 
.are like gourd-seeds (but are smaller). From the peculiarity of these 
ripe joints, which are continuously thrown off and passed with the stool, 
Ave are able to make the differential diagnosis between this and the other 






Fig. III. — Taenia solium, head 
enlarged (Heller). 



Fig. 112. — Taenia solium. 
Ripe joint, magnified 6 times 
(Heller). 



Fig. 113. — Egg of taenia 
solium (Heller). 



tape-worms. The joints show a longitudinal canal (the uterus), from 
which, toward both sides, as many as a dozen branches go off, which 
ramify like the branches of a tree. 

The eggs of T. solium (which require the use of a moderate micro- 
scopic power in order to find them, stronger to examine them carefully) 

^ See works upon Pathology. 



342 



SPECIAL DIAGNOSIS. 



are round, and, if they are ripe, have very thick shells (which show 
radiating lines, and which, with a little pressure upon the covering 
glass, break into hard pieces). In the finely granular contents we often 
see a few chitin-hooks. 

2. The Taenia mediocanellata seu saginata grows to 4 or 5 m. 
The head is somewhat larger than that of the solium, is also more 
strongly pigmented. It has no crown of hooks, but four sucking-cups, 
which are much stronger than those of the solium. On the whole, the 
rest of the worm, as respects its individual joints, is fatter and thicker 
than the first named. The ripe proglottides are passed not only by the 
stool, but wander independently from the anus, having strong, very 
energetic, independent movements. They are distinguished from those 
of the T. solium in that the uterus gives off more and finer branches on 
each side, which divide dichotomously. 

The ^^^ of the T. mediocanellata looks extremely like that of the 
T. solium, except that on the average it is somewhat larger. 






Fig. 114. — Tasnia mediocanel- 
lata. Head darkly pigmented 
(Heller). 



Fig. 115. — Taenia medio- 
canellata. Ripe joint, magni- 
fied 6 times (Heller). 



Fig. 116. — Egg of 

taenia mediocanellata 

(Heller). 



3. Bothriocephalus latus {sinus head) is found in South Germany, 
especially in South Bavaria, in the countries bordering on the North and 
Baltic Seas, likewise in the neighborhood of Lake Geneva and in the 
Baltic Provinces of Russia [in Sweden, Poland, Belgium, and Holland. 
" Low-lying damp regions near the borders of seas and lakes are those 
in which it is most often abundant"]. It [is the largest of the tape- 
worms, and] attains to 7 or 8 m. in length. Its head is elongated, and 
has two narrow, long-drawn-out sucking-cups. The illustration (Fig. 
118) shows its form and the shape of the uterus. The ripe joints are 
not given off singly, but a large piece of the worm is always passed at 
one time, and then, after a long interval, another; most frequently in 
the spring and fall. 

For this reason we here refer to the finding of the eggs (which are 
always present in the stools). They are oval (see Fig. 120), and much 
larger than those of the two other kinds of tape-worm. The shell is 
bright brown, relatively thin, and on one end of the oval has an opening 



EXAMINATION OF THE DIGESTIVE APPARATUS. 343 

which is closed with a cover of exactly the same kind. The contents 
of the ^^% are granular. 

As has recently become known, the bothriocephalus gives rise to 
severe anemia, with changes in the blood like those in severe pernicious 





Fig. 117 — Head Fig. 118. — Ripe joint of Fig. 119. — Egg of Fig. 120. — Eggofboth- 

of bothriocephalus bothriocephalus latus, en- bothriocephalus latus riocephalus latus, with de- 

latus, enlarged larged 6 times (Heller). (Heller). veloped embryo (Leuck- 

(Heller). art). 

anemia; for this reason, and because there are no joints thrown off, 
this tape-worm is very easily overlooked for a long time. 

4. Taenia cucumerina, 5-20 cm. long, 2 mm. wide ; the head is 
somewhat long and has sixty hooks ; the last joints are reddish and 
have the form of pumpkin-seed. Six to fifteen of the eggs lie together 
in the so-called cocoon. This worm occurs in dogs, cats, and not 
infrequently in man, especially children (Leuckart). Its pathological 
significance is not known (see Fig. 121). 




Fig. 121. — Taenia cucumerina (Birch-Hirschfeld). 
(2, joint, natural size ; b, the same with cocoons, enlarged 12 times ; c, cocoon, enlarged 290 times. 

Round Worms. — Ascaris Lumbricoides. — This is easily recog- 
nized from its likeness to the common earth-worm. Its habitat is the 
small intestine. Very frequently it gives rise to little or no complaint, 
but sometimes, and especially in children, it causes very uncomfortable 
phenomena of all sorts, particularly of the nervous system. Occa- 
sionally, when there is severe vomiting [and sometimes when there 
has not been any vomiting at all], it gets into the stomach, and is then 
vomited. Moreover, it may crawl into the ductus choledochus and 
thus cause obstinate jaundice. These worms appear in the stools, and 
sometimes, in sleep, they will crawl out of the anus. They may some- 
times come out of the mouth and nose while the person is sleeping. 



344 



SPECIAL DIAGNOSIS. 



The fresh eggs of the ascaris lumbricoides have a very peculiar 
appearance, since their chitin capsule is covered with an uneven, as it 
were, humped albuminous envelope (see Fig. 122). 




Fig. 122.— Ascaris lumbricoides (v. Jaksch). 
a, worm, natural size ; b, head ; c, egg. 





Fig. 123a. — Oxyuris 
vermicularis, natural 
size (Heller). 

I, Female ; 2, male. 



Fig. 123;^. — Egg 
of oxyuris vermicu- 
laris, enlarged (Hel- 
ler). 



Fig. 123^. — Oxyuris vermicularis, 

enlarged (Heller). 

a, ripe but unimpregnated female ; b, male ; 

c, female containing eggs. 



Oxyuris vermicularis is a small, white worm (Fig. 123^) found par- 
ticularly in the large intestine. It may wander from the anus into 
the vagina. It has very slight pathological significance. It appears 
in the stools, and also it is not infrequently found by itself in the 
neighborhood of the anus. When first passed it has usually very 
lively peculiar movements. The eggs are commonly unsymmetrical 
(see Fig. I23<^). 

Anchylostoma duodenale 
longer, even twice as loner 



is very like the last in form, but often 
it usually inhabits the upper part of the 
small intestine, especially the duodenum. 

Formerly it was only observed in other countries than Germany [dis- 
covered by Dubini in 1838 in Northern Italy], more recently also in 



EXAMINATION OF THE DIGESTIVE APPARATUS. 



345 



Switzerland (first during the building of the St. Gothard tunnel), and 
finally it was noticed among the inhabitants of the German mountains 
and among brickmakers. Because it continually sucks blood from 
the wall of the intestine it causes severe, sometimes fatal, anemia 
{anchylostoniiasis, formerly " Egyptian chlorosis," Griesinger). It is 
difficult to discover the worms in the stools unless some vermifuge is 
used, but, on the other hand, the tolerably characteristic eggs are 
always present. They are as large as, or perhaps a little larger than, 




Fig. 124. — Anchylostoma duodenale (von Jaksch). 
a, male ; b, female, natural size ; c, male ; d, female, slightly magnified ; e, head ; f, eggs. 

those of the oxyuris. They have a thick covering, and contain two or 
more segmentation globules. By allowing the stool to stand for 
several days in a warm place we can see the embryos develop in the 
eggs. In this very serious disease the stools often contain blood. 

Besides the intestinal parasites already mentioned, there are the fol- 
lowing, part of which are pathologically unimportant and others are 
very rare : 

Trichocephalus Dispar. — Its habitat is the colon, especially the cecum. 
It is of no importance. Both the worms and eggs are highly charac- 
teristic in form (see Figs. \2^a and 125^). 





Fig. 125a.— Trichocephalus dispar, natural 
size (Heller). 



Fig. 125^. — Egg of trichocepha- 
lus dispar, moderately enlarged 
(Heller). 



Trichina Spiralis. — It very rarely occurs in the intestine, but some- 
times in the first stage of the trichinosis, the stomach-stage with in- 
testinal phenomena, it is found in the stools. Since the early recog- 



346 



SPECIAL DIAGNOSIS. 



nition of trichinosis is of the greatest importance, in a suspicious case 
the stool is to be examined with the greatest care, best after the 
administration of an aperient. 

The appearance of the intestinal trichina is shown in Fig. 126. It 
is only one-third as long as the oxyuris, and hence cannot be seen with 
the naked eye. 

Distoma hepaticum and D. lanceolatum, two rare but patholog- 
ically important parasites which inhabit the gall-passages of the 





Fig. 127. — Trichina (von Jaksch). 

;, male ; b, female intestinal trichina ; t 
muscle trichina. 




Fig. 126. — Adult intestinal trichina, human. 
Male, female, and two embryos, the former natural 
size, the latter slightly magnified ( liirch-Hirschfeldj. 



Fig. 128. — Eggs of distoma hepati- 
cum and distoma lanceolatum, mod- 
erately magnified (Heller). 



liver, sometimes make themselves known by their eggs, which, passing 
out into the intestine with the bile, appear in the stools. The ^%g of 



EXAMINATION OF THE DIGESTIVE APPARATUS. 



347 



\ 



the D. hepaticum is much larger than the other parasites previously 
mentioned, about three times as large as those of ascaris lumbricoides. 
The ^g% of the D. lanceolatum is somewhat smaller than that of the 
oxyuris. For its other characteristics see Fig. 128. 

Microscopic Examination of the Feces. 

Mode of Procedure. — Thin or thin-mushy stools are examined 
without making any addition to them. To thick, mushy, or solid 
stools about \ per cent, of solution of salt is added, and the solid por- 
tions must, of course, be broken up. Somewhat of a selection must be 




Fig, 129. — Microscopical constituents of the stools (partly from v. Jaksch), 
a, vegetable fragments ; b, muscular fibers ; c, white blood-corpuscles ; d, saccharomyces ; e, micro-organ- 
isms ; f, crystals of triple phosphate ; g, fatty-acid crystals. 

made from the different portions of the stool according to the object of 
the examination. It has lately been recommended to mix the stools 
with water or a 5 per cent, solution >of salt, and then to centrifuge them. 
The solid portions of the stool must, of course, be first broken into 
small particles. It is said that the stratification which results from the 
use of the centrifuge greatly facilitates the examination. We have not 
yet employed the method. 

The degree of amplification is to be varied according to the object 
in view. In general, we employ dry lenses of high power. When 
looking for parasites (which have already been described) it is better, 
on the other hand, to make use of tolerably strong amplification. 

I. Undigested Portions of Food. — These may be found in every 
stool, and in varying quantities according to the kind of food eaten. 
We mostly meet with coverings of vegetable cells, elastic fibers, etc. 

«. Portions of Digested Food. — Although these, if visible with 
the naked eye, indicate disturbed digestioji in the small intestine, yet micro- 
scopical particles of these substances are seen in small quantities in nor- 
mal stools, as well as small portions of muscular fiber, with the trans- 
verse striations, shreds of connective tissue, starch-granules, and fat. 

But considerable quantities of the substances named always indicate 
disturbed digestion either in the small intestine or the stomach, and 
hence have the same significance as the occurrence of larger pieces, 
which can be seen without being magnified.^ When the microscopical 
particles are colored a bright-yellow, as we commonly see small por- 

^ See above, p. 347. 



348 SPECIAL DIAGNOSIS. 

tions, particularly of muscular tissue, but sometimes almost all the 
solid portions of the stools, it shows that there is unchanged bile in 
the stool and catarrh of the small intestine. 

Fat, in the shape of polygonal glassy lumps, of needle-shaped 
crystals, anc;! also in the form of drops is a very frequent constituent 
of the stools. The glassy lumps occur very frequently in health, and 
are often colored yellow or yellowish-red. They are recognized as 
fat, fatty acids, or soap by their transformation upon the addition of 
sulphuric acid, and, when warmed, into drops of fat (Miiller). Drops 
of fat occur in the stools with milk diet (hence, particularly in those 
of children), when taking cod-liver oil, hkewise castor oil, and, if there 
is intestinal catarrh, then in very considerable amount. 

The needle-shaped fatty-acid crystals are not without significance. 
They sometimes occur singly, and again in bundles and druses. They 
are changed by simply warming them, or by the addition of acid and 
then warming, into drops of fat, and this takes place whether they con- 
sist of fatty acids or (lime-) soap. 

When there are great numbers of fatty-acid needles it is a pathologi- 
cal sign of disturbance of the resorption of fat, as may result from 
shutting off of the bile from the intestine, from any form of enteritis, 
of tuberculosis, amyloid degeneration of the intestine, and, lastly, from 
disease of the mesenteric glands. 

However, we must mention here, further, that, according to recent 
investigations, after extirpation of the pancreas, the digestion of fat is 
diminished to an extraordinary degree, or even may be entirely sus- 
pended (Abelmann). In future, therefore, in cases of fatty diarrhea we 
must think of the pancreas. 

Detritus. — With respect to detritus in the stools little needs to be 
said, because we cannot determine separately a great number of the 
kernels, husks, etc. 

3. Additions to the Stools from the Alimentary Canal. — 
Mucus. — A microscopical quantity of mucus occurs in the stools of 
persons in health. Small glassy lumps of mucus, which come from 
the cells of plants, may also be present. Usually the examination 
with the naked eye is sufficient to determine whether there is a patho- 
logical admixture of mucus. 

It is necessary only to mention that a firm stool, abundantly inter- 
spersed with small light lumps of mucus, is observed with intestinal 
catarrh (Nothnagel). In these cases we can generally discover the 
mucus, if we carefully examine, without any artificial aid.^ 

Epithelium. — Some cylindrical cells, often in mucous metamorpho- 
sis, are a frequent occurrence. If the quantity is large, it indicates 
intestinal catarrh. Very abundant cylindrical epithelium occurs in 
chronic catarrh of the large intestine, especially in mucous colic, in 
this case caused by mucous " infarction." It has already been men- 
tioned^ that regular shreds of mucous membrane are found in the 
stools, also portions of tissue. 

Red and White Blood-corpiiscles. — These are present in quantities in 
fresh bloody and in purulent stools. When seen but once they do not 
have significance. 

1 See p. 337. 2 See p. 340. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 349 

4. Crystals. — Except the fat crystals mentioned above, there are 
almost no crystals which are brought into requisition for the purposes 
of diagnosis. Crystals of ammoniaco-magnesian phosphates ^ no doubt 
occur in the stools in enteritis and abdominal typhus [typhoid fever]. 
But they may also be found in any other stools if they are not kept 
separate from the urine and stand for a long time. 

Lime-salts of all kinds, partly with inorganic, partly with organic, 
acids in the form of wedges, dumb-bells, needles, etc., sometimes 
colored an intense yellow by the bile in the stool, have no diagnostic 
import. 

Charcots crystals, in appearance and probably also chemically 
entirely agreeing with the Charcot-Leyden crystals of asthma, are 
observed in rare cases of dysentery, typhus abdominalis [typhoid fever], 
intestinal tuberculosis, anchylostomiasis. 

5. Vegetable Parasites. — We may divide the large number of 
vegetable micro-organisms which we find in the stools, from the stand- 
point of clinical diagnosis, into two classes : 

{a) Those which, primarily, for clinical diagnosis are only of sub- 
ordinate significance, because we do not know that they have any 
definite connection with any diseases. Here also we class those which 
are indirectly harmful — that is, they cause abnormal decomposition of 
the intestinal contents. This class is extremely numerous, and great 
numbers of one kind or another are present in every stool. The 
knowledge of the different kinds has recently been greatly extended by 
the important labors of Nothnagel, Bienstock, Escherich, and others. 
But the point has not yet been reached which makes them as available 
for clinical diagnosis as the other peculiarities of the stools. For this 
reason we will treat of them only very briefly here. 

Of the fungus-spores we have (very rarely) that of thrush ^ in chil- 
dren who are suffering from thrush in the mouth. Yeast-fungus, and, 
indeed, the different kinds of tortula cervisiae (see Fig. 129, 5), occa- 
sionally occur in all stools, especially in the milk-stools of children. 
In intestinal dyspepsia with acid fermentation they are generally more 
abundant than in normal digestion. But the schizomycetes belong to 
the numberless micro-organisms v/hich are seen in every microscopical 
preparation of the stools, whether normal or pathological. Of chief 
importance are the micrococci and bacilli. A very large part of these 
are colored yellow or brownish with iodin and iodid of potassium ; 
others are colored by the same reagent blue or violet (Nothnagel). 
These latter, according to v. Jaksch, are increased in intestinal 
catarrh. 

We are now able to conclude that the knowledge of these 
intestinal bacteria furnish diagnostic indications of anomalies in 
intestinal digestion, and that the different kinds of bacilli possess 
extraordinary biological peculiarities. Some require for their rapid 
development a neutral or slightly alkaline reaction, while others an 
acid reaction of the intestinal contents ; some are aerobiotic, others 
anaerobiotic ; and, while some have the power to transform starch into 
sugar, others cause the decomposition of albumin. 

(b) Pathogenic Fungi. — These we are able to isolate, and from 

^ See these under Examination of Urine. ^ See p. 257. 



350 



SPECIAL DIAGNOSIS. 



them diagnosticate the disease they cause, as the tubercle bacillus in 
the sputum. 

Here also belong the pathogenic schizornycetes. These are — Koch's 
cholera bacillus, the bacilli of abdominal typhus, and tubercle. 

Cholera Bacilli (common bacilli) are the pathognomonic sign of 
Asiatic cholera. They are short, more or less crooked, which are 
sometimes connected one to 
another in such a way as to 
form " spirals " like a screw. 
The curve may be very slight, 
even wanting, or marked, even 
semicircular. In general, they 
are shorter, but thicker, than 
the bacilh of tubercle. 



,J|#«k 



i(% 






.V.'. .^M^1 






^?5- 

Fig. 130. — Comma bacillus, pure 
culture (prepared by Prof. Gartner). 
Zeiss's immersion lens yij, eye-piece 
No. 2, camera lucida. Magnified about 
600 times. 



\-).'i^n /.{ 









UL.J 






'I Ti^i 



'^ iSi\ ') lid'- 






• -^ ■ /,! I , • 









/ 



l/Vi^i 



' ) 



\ 1 1 



Fig. 131. — Cholera dejections upon a 
damp sheet, two days old (Koch). 

a, S-form bacillus, 600: i. 



Habitat ; Mode of Preparation. — They are particularly found in the 
free mucous floccules of rice-water stools, also very abundantly upon 
the linen soiled by the dejections, and, indeed, here after two or three 
days, provided the linen has been kept moist. A mucous floccule (or 
a drop of the stools) or some of the deposit on the linen is placed upon 
a covering-glass. First dry it in the air, then pass it two or three times 
through the flame of a spirit-lamp, and stain it with methylene-blue or 
fuchsin by warming it one to five minutes. The cholera bacilli are not 
stained when treated by Gram's method. 

These bacilli have been found, we may say, constantly in the stools 
of Asiatic cholera by a great many other examiners besides Koch, and 
they are found in no other stools. They must, therefore, diagnosti- 
cally be of pathognomonic value to even those who doubt Koch's 
teachings concerning their pathogenic character. 

But since the morphological peculiarities of the cholera bacillus in 
the microscopical preparation do not furnish an absolutely certain 
recognition, and, on the other hand, since there is no specific reaction 
(as with the tubercle bacillus), in order to determine an isolated or first 
case it is indispensably necessary to establish a pure culture.^ It is 
very important to point out that even the pure culture only has deci- 
sive value when the culture medium has exactly the right degree of 
alkalescence. 

^ See, regarding this, the works upon Bacteriology. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 



351 



Comma bacilli are also, in individual cases, found in the vomit of 
Asiatic cholera. 

A bacillus which is morphologically like the comma bacillus occurs 
in tooth-mucus (Lewis and Miller), and just such an one also in old 



--> "»V 



Fig. 132. — Cover-glass preparation of a mucous floccule in Asiatic cholera. Zeiss's 
homogeneous immersion ^^, eye-piece No. 2, drawn by a camera lucida. Magnified about 
650 diameters. 



cheese (cheese-spirals, Deneke). Biologically they differ from Koch's 
comma bacillus and from each other. 

Bacilli of Typhoid Fever. — These bacilli, which have been regularly 
found in typhus abdominalis, in the diseased portion of intestine, in the 
mesenteric e^lands, the spleen, and liver, in the kidneys, and also fre- 



quently in the blood,^ are, without question, to be 



regarded 



as the 



n'^'^jK' 



fi^ 



nW' <r 



Fig. 



r 

133-— Spirillum (Finkler and 
Prior), 700: I (Fliigge). 



~-^' \V"' ::r\^=i B;!^^, 







Fig. 134. — Typhus abdominalis bacillus in pure 
culture. Zeiss's homogeneous immersion lens ^^, 
eye-piece No. 2, drawn with camera lucida. Mag- 
nified about 650 times. 



exciting cause of this disease. They have also frequently been found 
in the stools and urine of typhoid fever patients. But since they are 
neither distinguished by their form (just at the end they are rounded; 
are about as long as the tubercle bacillus, but are much thicker — about 
one-third as thick as long) nor by a specific color-reaction from the 
1 See Appendix, and in works on Bacteriology. 



352 SPECIAL DIAGNOSIS. 

other bacilli which occur in the stools, especially from the bacterium 
coli coimmcne, which is constantly present in the intestines, their micro- 
scopical proof is wholly uncertain. But also pure cultures from the 
stools (and urine) usually do not give a decisive result, because they 
cannot be positively distinguished from the bacterium coU commune, 
the constant inhabitant of the intestines. Bacterial diagnosis of typhoid 
fever from the stools and urine is, therefore, impossible with our present 
resources. But the examination of the spleen-pulp or a roseola or of 
blood from a vein not infrequently furnishes pure cultures of typhoid 
bacilli which can be interpreted as nothing else, and is then decisive 
for the diagnosis of typhoid fever, particularly against miliary tubercu- 
losis and septic diseases. [The method of diagnosis by serum reaction 
is the most reliable at present known. See page 247.] 

The typhoid fever bacillus is best stained with methylene-blue or 
fuchsin in a dry preparation upon a cover-glass.^ 

Bacteria which are Found in Different Forms of Acute Intestinal 
Catarrh. — i. Bacterium Coli Commime. — This is found in "infectious 
intestinal catarrh," frequently in very great quantities. Sometimes in 
cholera-like rice-water stools it occurs in as great quantities and as 
predominantly as the comma bacillus occurs in cholera Asiatica. Often 
it may then lie in heaps upon and in flocks of mucus just like the 
comma bacillus. It may also migrate from the intestines into the 
various organs of the body. 

It can scarcely be doubted that this constant and usually harmless 
inhabitant of the intestines in such cases must be considered as the 
cause of the intestinal disease. I must doubt whether it is much more 
virulent for animals if a culture be made from the stool of a case of 
enteritis than from a normal dejection. Besides, it shows uncommonly 
great differences as regards morphological conduct, chemical effect, 
virulence, and energy of growth. The question whether the bacillus 
of typhoid fever is a variety of the bacterium coli commune is generally 
answered in the negative by German and in the affirmative by French 
bacteriologists. For the present, therefore, the question must be con- 
sidered as undecided. 

2. Bacterium Fin k I er- Prior. — This is a species of spirillum which 
may be considered as the cause of some cases of cholera nostras. It 
is found in great quantities in the dejections of such cases, and micro- 
scopically shows a certain resemblance to the comma bacillus, but may 
easily be distinguished from it by a pure culture. 

3. Other Bacilli. — Various other bacteria besides these have to be 
considered, but with which we are not more accurately acquainted, and 
they need not be considered as specific ; but they exist greatly dissemi- 
nated as saprophytes. They rapidly increase, especially when the atmo- 
spheric temperature is high. They act by their toxins. Milk, as is 
well known, is the article of diet by which, in the easiest manner, great 
quantities of bacteria and toxins enter the body. 

Regarding a bacillus enteritidis, which is probably specifically patho- 
genic, although rare, see Gartner's communication.^ Beck^ has de- 

^ For cultures, see Appendix. 

'^ Correspondenz-Blatt f. der Th'uring. Aertzvei-ein^ 1888, ref. Baumgarteii's Jahres- 
berichtf. 1888. 3 Rgf. Centralbl. f. klin. Med., 1892. 



EXAMINATION OF THE DIGESTIVE APPARATUS. 



353 



scribed a special streptococcus, and according to some other observa- 
tions it is not impossible that this streptococcus has a more important 
part in cases of acute enteritis than has hitherto been supposed. 

Tubercle Bacilli. — These are frequently found in tuberculous ulcers 
of the intestine. It is not yet sufficiently established whether they are 
always present, chiefly because not infrequently tubercular ulcers of 
the intestines do not have any symptoms, and particularly do not cause 
diarrhea, and so, often enough, the firm stools are not examined for 
bacilli. On the other hand, in phthisical patients tubercle bacilli 
are sometimes observed in the stools without there being any intestinal 
tuberculosis. They come from swallowing tuberculous sputum. The 
method of staining is the same as in examining the sputum. 

6. Animal Parasites. — Infusoria of different kinds are found in 
many dejections. They are probably all inhabitants of the colon, and 
appear in greater quantities when there is diarrhea, particularly when 
the evacuations consist of 
mucus. Catarrhal and more 
severe — i. e. ulcerous and 
necrotic — diseases of the 
mucosa of the large intestine 
seem specially to favor their 
existence and increase. Occa- 
sionally, perhaps, an increased 
importation per os — for in- 
stance, by drinking water from 
standing pools — may account 
for them. They consist of 
cercomonas, trichomonas, Par- 
amecium coli, balantidium coli, 
etc.^ 

It is doubtful whether these organisms have a pathogenic signifi- 
cance ; they are probably only saprophytic attendants of the conditions 
mentioned. 

Mode of Examination. — The fresh dejections must be examined on a 
warm stage. Lutz recommends to add some fresh saliva at body-tem- 
perature. The organisms can be easily found only while they move : 
when cooled they immediately become quiet, and are then very difficult 
to be seen. 

Chemical Examination of the Feces. 

This has great importance, which is increasing more and more at 
the present time from the continual improvement of the methods of 
examination, and by the increased means of knowledge regarding the 
digestion of food in the stomach and intestines of the healthy and 
sick. 

An examination of the food-value of the nourishment taken consists 
of the following : To exactly ascertain the quantities of food introduced 
into the stomach, with the percentage in it of amylacea, albumin, and 
fat or fatty acids. The principal difficulty here is to make out which 
portion of feces corresponds to a certain quantity of food introduced 




Fig. 135. — Monads from the feces (v. Jaksch). 

a, trichomonas intestinalis ; b, cercomonas intes. ; (T, 
amoeba coli ; d, Paramecium coli ; e, living monads ; 
/, dead monads. 



^ Compare Fig. 135. 



23 



354 SPECIAL DIAGNOSIS. 

within a certain space of time. This can be done only by separating 
the time of the experiment by pauses of fasting, which in turn has its 
difficulty in man, particularly in a patient. Assistance is derived from 
a coloring substance, as charcoal, given at the beginning of the experi- 
ment, better still at the beginning and end of it, which substance 
appears unchanged in the feces and makes its demarcation possible. 
A second difficulty exists in the fact that the secretions from the 
intestinal tract and the continual casting off of epithelia, which is 
probably more abundant than has hitherto been believed, add to the 
nitrogen and fat in the feces to a degree impossible to determine. 

We cannot find room in this compendium for the methods which 
have to be applied in this investigation, but we refer to the works of 
Fr. Miiller,^ of v. Noorden,^ and Abelmann.^ 

It is also necessary to state very briefly the results of the investiga- 
tions hitherto made, since we do not as yet have at hand any conclu- 
sions which are useful for diagnosis. We only mention that, according 
to F. Miiller, in slight enteritis only the fat is imperfectly absorbed, but 
that in severe disease of the intestinal mucosa (extended amyloid dis- 
ease) all food-stuffs are poorly absorbed ; that in passive congestion of 
the intestinal tract absorption is ver}^ slightly impaired ; finally, that 
deficiency of bile, as well as tuberculosis of the mesenteric glands, 
interferes with the absorption of fat. Regarding the effect of shutting 
off of the pancreatic juice, the chnical results of Miiller and the experi- 
mental ones of Abelmann are opposed to each other. According to 
the latter, which seem to us to be conclusive, the absence of pancreatic 
juice has the effect of reducing the absorption of albuminous substances 
to about one-half of the albumin administered ; that the amylacea are 
somewhat less reduced ; that the fat, however, although a part of it is 
split up, still appears in the feces completely undiminished in amount. 
The fat of milk, 30 to 50 per cent, of which is absorbed, forms an 
exception. The splitting of the fat also, which takes place without the 
pancreatic juice, must probably be explained by the action of micro- 
organisms. 

1 Zeitschr.f. klin. Med., Bd. xii. '^ Ibid., Bd. xvii. 3 Diss. Sirassburg, 1 890. 



CHAPTER VII. 
EXAMINATION OF THE URINARY APPARATUS. 



This comprises the examination of the urinary organs themselves 
and the examination of the urine. Indeed, in very many cases the 
latter examination only is made or it forms the chief part, whether in 
its relation as being the secretion of the kidneys, or whether it be in 
reference to admixtures or alterations of the urine which occur in the 
course of its transit through the urinary passages. The local examina- 
tion of the urinary organs is now not often required, but if it is, the 
result of the examination generally confirms the diagnosis. This direct 
examination, therefore, ought never to be neglected. Moreover, where 
the kidneys themselves are diseased there come into consideration 
certain resulting phenomena in the different organs of the body. 

EXAMINATION OF THE KIDNEYS. 

Anatomy. — The kidneys, about lo to 12 cm. long, about 5 cm. 
broad, of well-known form, lie upon the two sides of the spinal column, 
upon the anterior surface of the quadratus lumborum muscle and the 
lumbar portion of the diaphragm, and reach from the level of the 
twelfth dorsal vertebra to the level of the second or third lumbar ver- 
tebra. The lower portions diverge somewhat downward, and hence lie 
with their lower ends somewhat farther from the median line of the 
body (about three fingers' breadth) than the upper ends (about two 
fingers' breadth). The right kidney is a little lower than the left. 

The upper half of each kidney is covered by the eleventh and 
twelfth ribs, the extreme upper portion also by the complementary 
pleural sinus (see Fig. 136); hence the lower border of the lungs does 
not extend so low as the kidneys. It is very important to note 
that the outer border of each kidney corresponds tolerably exactly 
with the outer border of the thick fleshy layer of the sacro-spinaHs 
muscle. 

The left kidney at its upper end, rather by its suprarenal capsule, is 
in contact with the spleen ; the right kidney, with the under surface of 
the liver. Both organs encroach upon the upper end of the kidney of 
their respective sides, like the tiles of a roof (see Fig. 136). The figure 
also furnishes information regarding the so-called spleen-kidney and 
liver- kidney angle. 

The anterior surface of each kidney is covered by the parietal peri- 
toneum, and in front of it lies the ascending or descending colon. The 
anterior inner border of the right kidney is not far from the ductus 
choledochus and the duodenum. 

355 



356 



SPECIAL DIAGNOSIS. 



In the rare condition known as Jioj'seshoe kidney, the lower ends of 
the two kidneys are connected by a transverse band consisting of kid- 
ney-parenchyma. This transverse portion passes, like a bridge, across 




Fig. 136. — Anatomical situation of the kidneys (Weil). 
a, d, borders of the lungs ; c, e, limits of the pleural sacs ; f, angle between the spleen and kidney ; g, angle 

between the liver and kidney. 

the aorta and the spine, about on a level with the second lumbar 
vertebra. 

I/Ocal Bxamination of the Kidneys. — In every respect its 
result is almost negative. 

Inspection. — The normal kidney, of course, cannot be inspected. 
In remarkably exceptional cases we may, by employing bimanual 
palpation, with the legs drawn well up (one hand being placed 
behind in the lumbar region and the other pressing deeply in front), 
get some information, provided the abdominal covering is very un- 
usually lax and thin and the stomach is empty. Of late percussion 
of the kidneys has very rightly come more and more into discredit. 
It must be perfectly evident that it is impossible to point out the 
normal kidneys, or even moderately enlarged ones,^ if one remembers 
that the kidney is less voluminous than the spleen ; that, moreover, it 
lies much less favorably ; and, besides, if he takes into consideration 
how often the normal spleen is with difficulty or cannot at all be made 
out. The kidney is unfavorably located for percussion, because the 
sacro-spinalis muscle (of considerable mass) lies over it, but especially 
for the reason that its lateral border almost exactly corresponds with 

^ See below. 



EXAMINATION OF THE URINARY APPARATUS. 357 

the convex border of the kidney. So we cannot with certainty deter- 
mine whether the kidney Hes under the muscle nor where its Hmits 
are. 

Individual exceptional cases, where very thin or atrophic sacro- 
spinalis muscles permit of percussion of the kidneys, may nevertheless 
occur, as the cases mentioned above, where the normal kidneys can be 
felt. But we cannot consider the result of percussion of the kidneys as 
of great value. 

We know of a case where a movable tumor in the left side of the 
abdomen was pronounced to be a floating kidney by a recognized 
master of percussion on account of a tympanitic resonance in the left 
renal region. The patient had been carefully examined innumerable 
times. An operation was performed on account of intolerable pain, and 
a floating spleen was found. It was removed, however, with a lasting 
favorable result. 

Pathological Conditions of the Kidneys. — Inspection. — The 
kidney can only be inspected when it is very much enlarged or enlarged 
and displaced. Tumors of the kidney may make their appearance in 
the lumbar region, in the side, and in the lateral anterior portion of the 
abdomen near the border of the ribs. According to their nature, they 
are smooth, roundish, irregular, or uneven.^ They do not move with 
respiration. Their appearance may strikingly vary, but not necessarily 
so, with the changes of position of the body (the dorsal position, stand- 
ing). If the tumor is very large it generally presses the colon, ascend- 
ing or descending-, toward the anterior abdominal wall, and then the 
colon, according to the amount of its distention, may lie up against the 
abdominal wall.^ 

If the kidney is the seat of a tumor, it very often departs from its 
place close against the diaphragm and becomes the so-called wan- 
dering kidney. In this case it is much easier seen from in front. A 
normal kidney wandering so much as to be visible is a curiosity 
(Bartels). 

A roundish, symmetrical swelling located in the dorsum in the 
region of the kidney or somewhat side wise from it points to purule7it 
perinephritis. Sometimes it extends upward in the abdominal cavity, 
from the diaphragm being pushed up. Often there is edema of the 
skin at the spot (deep formation of pus^) or there may be inflammatory 
redness. Moreover, abscess, due to the congestion accompanying 
caries of the spine, may break here. Also, large perinephritic abscesses 
have been seen as tumors above the border of Poupart's ligament in the 
ihac region. 

Palpation. — This is most important in the local examination of the 
kidneys. We employ it in the dorsal position with the knees well 
drawn up, but sometimes also in the abdominal position. In both 
cases we always first examine bimanually, one hand being upon the 
region of the kidney and the other upon the abdomen. 

Tenderness upon pressure occurs : sometimes in acute, almost never 
in chronic, nephritis ; also in tumor of the kidney, stone in. the pelvis 
of the kidney if it excites inflammation ; in inflammatory hydronephrosis 
and in perinephritis (here there is often very great sensibility). 

1 See Palpation. ^ See p. 48. 



358 SPECIAL DIAGNOSIS. 

When the kidney is enlarged from engorgement, amyloid disease, 
or nephritis (large white kidney) it is never perceptible to palpation 
except it leave its place/ or we have one of the exceptional cases in 
which even a kidney of normal size and location can be felt.^ Very 
large new formations, as carcinoma, sarcoma, hydro- and pyonephro- 
sis, echinococcus, and perinephritis only are palpable. The tumor can 
be felt in one side of the lumbar region or at one side of the anterior 
abdominal region. With new formations it is unusually uneven ; in 
hydronephrosis, smoothly round, more or less tense ; under some cir- 
cumstances fluctuation can be distinctly made out, Echinococcus is 
usually smooth and tensely elastic ; it may show hydatid vibration.^ 

It is important to remember that tumor of the kidney is only very 
rarely movable upon pressure (for if it descends, then we have a wan- 
dering kidney). We have never seen a case w^here one moved with 
respiration, but it seems that in some cases there is this movement. 
At any rate, the absence of respiratory movement points to the kidney, 
and especially against the spleen or a tumor fixed to the liver. 

In a considerable number of cases it will be found that the ascend- 
ing colon and descending colon are in front of the kidney-tumor and 
pressed by it against the abdominal wall. In these cases this fact has 
great value for differential diagnosis. In other cases the tumor will be 
found lying exactly in the median line, and then it is of significance for 
differential diagnosis, especially from ovarian tumor. The location of 
the colon, moreover, is usually only made out with certainty when it 
can be felt, and particularly when it contains air. It is therefore 
advisable to inflate it.* 

Floating Kidney ; Movable Kidney. — By this we understand down- 
ward dislocation of the kidney, whether much or little. Frequently 
a dislocation is a partial phenomenon of a general enteroptosis. Almost 
always only one kidney, usually the right one, is dislocated. In 
these cases the kidney is commonly of normal size, but it may be 
enlarged, and this is most frequently due to hydronephrosis caused 
by the bending of the ureter, or also because it is the seat of a new 
formation. 

It is generally veiy easy to recognize a kidney that is very much 
out of place, but when it is still high up, near the liver or the spleen, 
it is often very difficult to do so. The diagnosis is based upon the 
bean-shaped form of the kidney, eventually upon its being of the 
appropriate size, and upon its mobility by pressure, which is almost 
never wanting ; also, sometimes, with the changes of position of the 
body. Not infrequently the kidney can be perfectly replaced. In 
some cases dyspeptic symptoms, even dilatation of the stomach, also 
jaundice from engorgement, have been observed when the right 
kidney was displaced (from compression of the duodenum or of the 
ductus choledochus. Those cases where the pulse can be felt in the 
renal artery are rarities. 

Percussion. — We employ percussion to establish the existence of 
tumors of the kidney, which give a deadened sound on account of their 
solidity, but they are almost always clearly made out by palpation. 

1 See Floating Kidney. ^ c^gg above, Normal Position of Kidney. 

' See above, p. 292. * See p. 280. 



EXAMINATION OF THE URINARY APPARATUS. 359 

Its value in determining dislocation of the kidney was formerly very 
much overrated. It was thought that we were able to prove one-sided 
dislocation of the kidney because, when the patient was lying upon 
the abdomen, the resonance of the two sides in the neighborhood of 
the kidneys was found to be different — clearer upon the side of the 
wandering kidney, in contrast with the absolute dulness of the normal 
side. In our opinion, even in the most favorable cases, such a condi- 
tion cannot be employed for deciding the diagnosis. 

But, on the other hand, percussion may be of the greatest value, 
either to determine the relation to the colon of a tumor in one side of 
the abdomen, or to determine the course of the colon over a tumor of 
the kidney.^ In such a case distending the colon with air- is of the 
greatest assistance. Further, it might possibly occur that a consider- 
able enlargement of the kidney could be made probable (never certain) 
by an area of dulness upon the back extending from the region of the 
kidneys toward the side. 

Differential Diagnosis of Tumor of tlie Kidney. — The posi- 
tive evidence of tumor of the kidney has just been spoken of We 
may have to make a differential diagnosis between a luandering right 
kidney which is not very much displaced downward and a distended 
gall-bladder, or an echinococcus located upon the lower surface of the 
liver. If there is respiratory mobility, this speaks against it being the 
kidney, but if the tumor can be replaced, so that it may even disappear, 
then it speaks for it being the kidney. Both wandering kidney and a 
pedunculated echinococcus may be easily movable upon pressure. It 
may often be impossible to determine exactly the form of a tumor 
situated close under the liver. 

A zuaiidering left kidney is distinguished from a wandering spleen 
by its form, which is made out by percussing the neighborhood of the 
region of the spleen : in wandering spleen we may find notches ; if it is 
the kidney, we may feel the pulse at the hilus. We distinguish tumor 
of the left kidney from tumor of the spleen by the form and relation to 
the colon. Sometimes respiratory mobility decides in favor of the 
spleen, but this may also be wanting; while notches on the upper 
border of the tumor may speak with probability for the spleen ; yet in 
one case, where they could be very distinctly felt, they led us to a false 
diagnosis ; it was found to be a carcinoma of the kidney. 

EXAMINATION OF THE URETERS AND BLADDER. 

Ureters. — Simon, by introducing the hand into the rectum, has re- 
peatedly felt the ureters.^ Recently, Heger-Kaltenbach and Sanger have 
proposed, in the case of women, to palpate them per vaginani. We can 
feel their lower ends where they come down on either side of the neck 
of the uterus and enter the lower side of the bladder. With some 
practice often even a normal ureter, but still more one that is thick- 
ened, can be felt in the lateral and anterior fornix vagince and the ante- 
rior vaginal wall close to the middle line. 

In this way it is not difficult to recognize thickening or tenderness 
of one or both ureters occurring in cystopyelitis and in tuberculosis of 

^ See above. ^ gge p. 2S0. ^ See works upon Surgery. 



360 SPECIAL DIAGNOSIS. 

the urinary apparatus ; thickening and distention may sometimes be 
observed also in pyelitis caladosa (renal calculus). 

Bladder. — The bladder hes behind the symphysis pubis ; when ordi- 
narily distended it rises above it ; but only when it is excessively full, as 
in paralysis of the bladder, spasm of the sphincter, stone in the bladder, 
stricture of the urethra, does it swell so much as to be noticed (rarely) 
by inspection, but especially by palpation and percussion, as a roundish 
tumor, which of course is dull in sound. In men it can also be felt 
from the rectum. We are able to decide with certainty whether a 
tumor in the hypogastrium is a distended bladder or not by drawing 
off the urine with a catheter. It may be confounded with a pregnant 
uterus and also with other swellings. Always before undertaking an 
examination of the abdomen we must see that the bladder is empty, 
partly to avoid confounding the distended bladder with something else, 
and partly because, if the bladder is full, it interferes with the examina- 
tion of the abdomen. 

F. Miiller has ascertained that it is necessary to have 500 to 600 
c.cm. of fluid in the female bladder, and 360 to 500 c.cm. in that of the 
male, in order to have dulness upon percussion over the bladder. 

Anomalies located in the wall of the bladder can usually be felt best 
when the bladder is full. The external examination is made per vagi- 
nam, per rectum^ and sometimes bimanually. 

Surgery and gynecology teach the complicated methods of examin- 
ing the bladder and ureters. With reference to the examination of the 
male urethra we refer to works upon Surgery. 

EXAMINATION OF THE URINE. 

Under normal conditions and free from admixture, the urine ex- 
hibits the renal secretion in a state of purity only as it issues from the 
orifice of the ureter, since in its transit through the urinary passages it 
receives a few epithelial cells and micro-organisms ^ from the mucous 
membrane — additions, however, that are scarcely worth mentioning. 
At the time of its discharge from the body and for some time after 
its physical and chemical conditions are the same as at the moment 
of secretion. In a number of pathological conditions also the urine is 
the pure and unaltered secretion of the kidneys ; while in a second 
series of diseases it is changed by its exit from the body by ad- 
mixtures from the urinary passages, or by decomposition of its con- 
stituents in the bladder. To the first series belong the anomalies of 
the secretion itself; to the second, the diseases of the urinary pas- 
sages. 

In women the urine may be contaminated by admixture of material 
from the vagina or uterus, and of these the most frequent and impor- 
tant is the menstrual fluid. In order to avoid this contamination we 
are sometimes obliged to draw off the urine with the catheter. It is 
usually contaminated by fecal material only from carelessness of the 
patient or of the attendant. But sometimes it results from communica- 
tion of the intestine with the urinary passages, as of the rectum with 
the bladder or with the vagina. 

^ See below. 



EXAMINATION OF THE URINARY APPARATUS. 36 1 

In examining urine for bacillus tuberculosis it is sometimes neces- 
sary to guard against its being contaminated by the patient's sputum. 

Recent investigations by Lustgarten and Mannaberg show that the 
former assumption that the urine is normally free from bacteria must 
be given up. The urine of healthy persons contains a number of micro- 
organisms which have their origin in the urethra. The most important 
are a large streptococcus ; a diplococcus which resembles the gonococcus, 
also like that in epithelium, but of course it is not found in pus-corpus- 
cles ; and, lastly, a bacillus which morphologically and in its color- 
reactions agrees with the tubercle bacillus, and which probably is the 
smegma bacillus, which also occurs in the preputial sac. This latter 
may give occasion for the erroneous supposition that there is tuber- 
culosis. But that it has its origin in the urethra is shown by the fact 
that it is observed even when the preputial sac has been most carefully 
cleaned previous to urination, though it is only found in individual 
cases, while in cases of tuberculosis it is always abundantly found in 
the urine. Sometimes inoculation must decide.^ We may avoid the 
urethral bacillus by drawing the urine with a catheter, but then also, 
sometimes, possible tubercle bacilli from the prostate or genital appa- 
ratus may be found in the urine. 

In case of disease of one kidney or pelvis of the kidney the question 
may arise as to what part of the urine passed is from the right, and 
what from the left, kidney. If one kidney fails, the other acts vicari- 
ously. In tuberculosis of the urinary passage and in pyelitis it may 
happen that for a time one ureter is stopped ; the urine comes only 
from the other kidney, and it may be quite normal. Then, suddenly, 
the character of the urine will change, showing considerable white 
blood-corpuscles, seed-like particles, tubercle bacilli, or calculi and 
blood. The quantity of urine is, for the time being, increased, for the 
closed side has again opened.^ 

In certain diseases of the urinary apparatus the manner of passing 
the nrine shows characteristic peculiarities ; but in many of the condi- 
tions under consideration the urine is passed in a perfectly normal way. 
Painful strangury, frequent urination, a feeling of burning in the urethra 
while passing the urine, may result from the urine being much concen- 
trated, such as is passed when there is engorgement of the kidneys and 
in the majority of cases of acute nephritis. Very pronounced tenesmus 
of the bladder — that is, painful urgency, extremely frequent, very pain- 
ful urination, in which only a small quantity of urine is passed at a time 
— indicates cystitis. We must mention here, further, retention and 
incontinence of urine and nocturnal enuresis.^ 

In regard to tlie mode of procedure in examining the urine, let it 
be here remarked, in the first place, that we should take care that the 
urine is received into vessels that are perfectly clean — if possible, in 
glass vessels ; and also that for judging of certain general characteristics 
it is necessary to examine the mixed urine passed during twenty-four 
hours, or that passed during the day and during the night, separately. 
For certain examinations it is necessary to separate, in the most careful 
way, the urine passed each twenty-four hours. In the warm season of 

^ See Appendix. 2 g^g page 367. 

^ Regarding these, see under Examination of the Nervous System. 



362 SPECIAL DIAGNOSIS. 

the year the urine ought to be examined as soon as possible after it is 
passed. [Sometimes the nurse may be directed to add a few drops of 
chloroform or of a 50 per cent, solution of chloral hydrate to the urine 
immediately after it is voided. This will prevent decomposition and 
development of bacteria till it can be analyzed.] In order to examine 
the sediment the upper portion of the urine is to be carefully poured 
off, and the remaining cloudy portion is put into a conical glass, in 
which it is allowed to stand till the sediment is deposited ; then with 
a pipette we take up a few drops from the bottom of the glass.^ 

When there is unconsciousness or difficulty in passing the urine 
we must employ the catheter. The artificial emptying of the bladder 
for the purposes of examination must never be omitted in any case of 
unconsciousness. 

The examination of the urine comprises the following points : the 
anwiDit [in twenty-four hours], its color and transparency, specific 
gravity, reaction, odor. In addition, the urinary sediments and con- 
stituents in solution must be studied. We briefly describe the charac- 
teristics of normal urine. 

(A) Normal Urine. 

1. Amount. — In twenty-four hours, with healthy persons, it amounts 
on the average to about 1500 grams. But its variations within physi- 
ological limits are very considerable, since every increase in the amount 
of water taken increases the amount of the urine, and every increase in 
the amount of water disposed of in other ways [by perspiration, 
respiration, vomiting, and diarrhea] diminishes the urine. In the latter 
respect, in health we have to consider the loss of water by respiration 
and by perspiration from heat and from active bodily exertion. It is 
superfluous in the cases just referred to to specify the maximal and 
minimal figures for the amount of the urine ; only when those condi- 
tions are wanting must a departure from the average quantity of urine 
given above cause us to think of a pathological condition. 

Within the twenty-four hours the least urine is passed at night or 
in the early morning, very much the greater portion being passed 
during the course of the day, Quincke estimates that the amount of 
urine excreted hourly in health during the night, compared with the 
amount during the day, is in the proportion of one to two or three. 
Usually, the amount of urine passed increases about an hour after 
taking fluid. Emotional excitement, especially anxiety, sometimes 
temporarily increases the secretion of urine. 

2. Color ; Transparency. — In health the color is usually dark 
straw-color to reddish-yellow. Generally, the greater the amount of 
urine the clearer it is. In this respect, as well as in the quantity, with 
physiologically exceptional cases, it shows marked variations from the 
average — from being almost as clear as water after a great amount of 
fluid has been taken, to a decidedly dark reddish-yellow (concentrated 
urine) after severe sweating. The coloring materials which give the 
normal color to the urine are not yet all exactly known. The most 
important pigment seems to be urobilin ; moreover, indican interests 

^ Regarding the use of the centrifuge for shortening this part of the process, see page 374. 



EXAMINATION OF THE URINARY APPARATUS. 363 

the clinician. Both coloring materials may, in disease, be pathologi- 
cally increased.^ 

Urine freshly passed, in health, is always perfectly clear and trans- 
parent, but in these respects it may change some time after it has been 
passed. 

(ci) In almost all normal urine, after standing a short time, there is 
formed a slight cloud of mucus {imbecidd). It consists of a mucin-like 
substance which in part is probably mucin, in part an albuminous sub- 
stance related to it, nucleo-albumin. Both substances are present in 
every specimen of urine, part of which is precipitated as a cloud of 
mucus, but part also remains in solution. This is from the urinary 
passages, chiefly from the bladder. It is increased, not only in many 
diseases of the urinary apparatus, particularly of the urinary passages, 
but also in health. As it is precipitated by some of the albumin tests, 
it may simulate genuine albuminuria. 

{b) It not infrequently happens, with healthy persons, that the 
urine, if somewhat concentrated, is cloudy when it becomes cool, 
from the separation of the uric-acid salts. Gradually the salts sink 
and form a sediment of clear brickdust-red or flesh color (associated 
coloring matter of the urine, brickdiist sediment, lateritious sediment). 
It has the peculiarity — by which it is likewise recognized — that it is 
again immediately dissolved as soon as the urine is warmed. After a 
long march in the heat this sediment occurs very regularly, because 
the urine is then concentrated, but it also is observed in urine that is 
not so very dark if allowed to stand in a cool place.^ 

(c) Urine that stands exposed for a long time, both clear and dark, 
likewise sometimes becomes cloudy because it undergoes ammoniacal 
fermentatio?i. The urea is changed into carbonate of ammonia, which 
makes the urine alkaline, whence there is a deposit of phosphates 
(ammonio-magnesian phosphates or triple phosphates, also phosphate 
of lime). Urate of ammonia also is formed and deposited. These 
separations and numerous bacteria render the urine cloudy and grad- 
ually form a whitish sediment. In hot weather this ammoniacal fer- 
mentation takes place within a few hours after the urine is passed ; in 
a cool place it does not begin before thirty-six to forty-eight hours, or 
not at all.^ 

3. Specific Gravity. — In health it usually varies between 1015 
and 1020. It depends upon the amount of solids held in solution by 
the urine ; hence, on the one hand, upon the absolute quantity of the 
solids, and, on the other, of the amount of the watery portion of the 
urine or the quantity of the urine. The abundant urine which follows 
drinking a great amount of water is always of low specific gravity, and 
therefore clear. A scanty urine, from the loss of water in other ways, 
is always of high specific gravity, and hence is dark. Then, also, in 
health the specific gravity, under some circumstances, temporarily over- 
steps very considerably the figures given above — from as low as 1003 
to as high as 1025, or even higher. In the absence of "physiological 
causes " these figures are always of pathological significance. 

^ See Pathological Color of Urine. ^ ggg further regarding the Urinary Sediments, p. 386. 
3 For a more particular account of the condition when there is ammoniacal fermentation 
of the urine, see p. 373. 



364 SPECIAL DIAGNOSIS. 

Mode of determining : We measure the specific gravity of the urine 
by means of an araometer, graduated for taking the specific gravity of 
the urine (that is, from looo to about 1040 — urinometer). We take a 
portion of the urine which we wish to weigh (generally a mixture of 
that which has been passed during the previous twenty-four hours) and 
pour it into a not too narrow cylindrical glass until the column of urine 
is longer than the urinometer. With filter-paper or a pipette we remove 
any air-bubbles from the surface, and then introduce into it a perfectly 
clean and dry urinometer, wait until it has become quiet, and then observe 
the figure that stands opposite the lower border of the meniscus of the 
fluid. [It should not be read from below the surface of the fluid, but 
from above. The division of the stem nearest the general level of the 
liquid is the one to select.] 

[To overcome the inaccuracies which inhere in most urinometers 
Dr. Squibb has proposed two important modifications, that the air- 
chamber of the hydrometer should be that of a double cone, and that 
the jar containing the urine should have its sides indented so as to 
make an inverted V-shaped projection inside the jar. Both of these 
reduce to a minimum the friction between the surfaces.^] 

None of the simple medical instruments is so often useless as the 
urinometer. We should never use one until its accuracy has been tested. 
It is always desirable to have a urinometer upon which is given the tem- 
perature for which its scale is arranged; not that we must always have 
the urine at this temperature, but because the absence of this declaration 
from the instrument shows very certainly that it has been prepared 
without care. The scale is arranged for a temperature of 15° C. — i. e. 
about room-temperature. When the temperature of the urine differs 
considerably from this — for instance, when it has been recently passed 
or has been kept in a cold room in winter — considerable error results. 
Then it is necessary to add or subtract one degree on the urinometer 
for each three degrees Celsius which the temperature of the urine is less 
or exceeds that prescribed for the urinometer. 

4. Reaction. — In general this is always acid, chiefly from the 
presence of acid urates and phosphates. The degree of acidity varies 
individually ; moreover, it is a constant quantity in every individual 
case of health and when the food is approximately alike. 

But in the twenty-four hours the reaction varies considerably, so as 
to be even alkaline and yet physiological. The variations proceed in 
such a way that after every meal consisting of a mixed diet the acidity 
declines until, after about two hours, it becomes alkalescent ; but this 
quickly passes, so as to give place again to an acid reaction (Gorges). 
These variations have been referred by many to the loss by the body 
of acids and alkalies in stomach and intestinal digestion. Hence it is 
assumed that the separation of HCl in the stomach increases the alka- 
lescence of the blood, and hence the urine becomes less acid, or alka- 
line. But, according to recent investigations by v. Noorden, this increased 
alkalinity of the blood does not exist. By a graphic representation of 
the reaction of the urine during twenty-four hours we obtain the so- 
called "acid-curve." This, with some healthy persons and under Hke 

^ See Squibb's Ephemeris of Materia Medica, vol. i. p. ZSI ff- 



EXAMINATION OF THE URINARY APPARATUS. 365 

conditions as to time and quality of food, is tolerably constant, but with 
other healthy persons it varies considerably. 

Sometimes the reaction of the urine is amphoteric — that is, it colors 
red litmus blue, and at the same time colors blue litmus red. 

The neutral or alkaline urine of health at the time of passing is 
usually clear. But it quickly becomes cloudy from the withdrawal of 
the phosphates, which gradually form a sediment. The cloudiness 
does not disappear upon the application of heat, but becomes more 
marked ; on the other hand, the urine again becomes clear upon add- 
ing acetic acid, in consequence of the solution of the phosphates. 

5. Odor.— The normal aromatic odor of urine is well known ; it is 
changed by certain foods. Most frequent and most striking is the 
stench of urine after eating asparagus ; garlic gives its odor to the 
urine. During alkaline fermentation we may have the development 
of ammonia, which gives its known pungent odor. 

6. Sediments. — With reference to the cloudiness the urate sedi- 
ment of the acid and the phosphatic sediment of the alkaline urine have 
been mentioned on page 363. Regarding the microscopical condition of 
the sediment, see page 360. By the use of the centrifuge it has been 
found that isolated casts and red and white blood-corpuscles are 
present in the urine of persons who show no other morbid signs, par- 
ticularly also no chemically demonstrable albuminuria. 

Whenever there is a sediment it is not unimportant to remember 
that different things may have been mixed with the urine after it was 
passed.^ 

7. Micro-org'anisms. — Regarding these, see what has been said 
above, page 361. 

8. Urinary Constituents in Solution. — The constituents of 
normal urine besides the coloring-materials, which, from our present 
knowledge, are of importance to the clinician, are the following : urea, 
uric acid, creatinin, oxalic acid, chlorid of sodium, sulphates, phosphates, 
carbonates. 



Urea 



CO^TT^ > passed in twenty-four hours amounts in the adult 

to about 30 grams (men somewhat more, women somewhat less). 
However, the amount of urea varies within wide limits : it is dependent 
upon the amount of albuminous material in the food taken, and, on the 
other hand, it is usually independent of the amount of muscular 
exertion. 

Uric acid, like urea, is a product of the metabolism of albumin ; in 
man the quantity is much smaller than the former, being in proportion 
to the urea about as I : 45 ; but it is to be remarked that great 
variations take place, chiefly under the influence of the food, and this 
in such a way that albuminous food increases the acidity of the urine. 
With reference to clinical diagnosis, the uric acid and also the creatinin 
are chiefly of interest, because they may place difficulties in the way in 
examining the urine for sugar, in that they sometimes simulate the 
reaction of sugar. Sometimes, on the other hand, they hinder the 
reaction of sugar.^ 

Chlorid of sodium, the most important of the inorganic constituents, 
1 See above, page 360. 2 ggg under Mellituria. 



366 SPECIAL DIAGNOSIS. 

in health corresponds in amount with tolerable exactness to the amount 
of salt in the food taken. On the average, it usually is proportioned to 
the urea as i : 2 to i : 3. 

Exceptionally, in health, there are found in the urine the following : 

Albumin, the so-called physiological albumin. There is still great 
difference of opinion regarding this subject : while it is doubted by 
some, others maintain (Senator, recently Posner) that traces of albumin 
exist in the urine in every healthy person. It occurs in very small 
quantity (about i per cent.) after severe exertion or hearty eating. 
The urine of the newly-born not infrequently contains some albumin 
(compare what has already been said on page 363). 

Sugar may occasionally appear in small quantities in the urine (o.i 
to 0.25 per cent, Moritz) after over-abundant use of food and drinks 
containing sugar (confectionery, etc., sweet champagne, even great 
quantities of beer). This alimentary glycosuria is possibly favored by 
individual disposition. At the same time, however, it seems that we 
are not justified in considering persons who show these signs after 
indulgence in sweets as disposed to diabetes. Sugar of milk to the 
extent of 0.8 to I, even 2 per cent, appears during confinement and 
also lactation. 

Reducmg substances, which are not sugar, are present in every 
normal urine, but only exceptionally can they be demonstrated by the 
common tests. The reduction is very slight, perhaps about o.i to 0.22 
per cent, solution of grape-sugar (Moritz). Generally, the quantity of 
reducing substances seems to go parallel with the excretion of nitro- 
gen. Uric acid and creatinin take the principal part in the reduction. 

Bile-acids are hkewise observed in very small quantities in normal 
urine. 

Fat is recognizable generally only in microscopical drops (or only 
in ether extract), and is found when the food has contained a great 
abundance of fat, as of cod-liver oil. 

(B) Pathological Urine. 

Anomalies in the Quantity. — Increased amount of urine 

(^polyuria) is observed — 

1. In a watery condition of the blood in the different forms of 
anemia or hydremia. The increase here is never very great : 2000 
grams or less ; there may be no increase, and if the heart is weak it 
may even be diminished.^ 

2. In the different forms of contracted kidney, and this in conse- 
quence of the accompanying hypertrophy of the left ventricle, which 
causes increased pressure in the whole arterial system, and thus also 
in the renal arteries: here even to 3500 grams or more. Here the 
chief cause of the polyuria is the increased arterial pressure from the 
increased action of the heart. ^ 

3. When the exudation or transudation in the serous cavities of the 
body or the fluid in the cellular tissues (edema) is resorbed, the daily 
excretion of urine sometimes amounts to 4000 grams or more. The 
increased arterial pressure ^ from quickening of the action of the heart, 



See page 368. ^ See page 368, under 3. 



EXAMINATION OF THE URINARY APPARATUS. 36/ 

which occurs at the same time, is also a prominent factor in producing 
polyuria. 

4. In diabetes. Both diabetes insipidus and mellitus (mellituria) 
manifest themselves by the increase, often an enormous amount 
of urine, 4000 to 10,000 grams and more. Sometimes in dia- 
betes mellitus there is only a moderate polyuria, or, for a time, in 
this disease there is even complete absence of polyuria (diabetes 
decipiens).^ 

5. Nervous polyuria (urina spastica, nervosa). This may occur tem- 
porarily or paroxysmally in attacks of migraine, epilepsy, in psychical 
excitement of nervous persons, but it may also be of longer duration, 
as in hysterical neurasthenic people. Sometimes there is a periodical 
flood of urine having a nervous origin. 

6. As a necessary consequence of abnormal thirst, polydipsia, as it 
is sometimes observed, particularly in hysteria. 

7. A periodic (or better, a temporary) flood of urine, which occurs 
only once in a while, is sometimes observed in conditions which suggest 
a temporary exclusion of one kidney.^ These are cases of tuberculous 
and catarrhal ureteritis with obstruction of the ureter by swelling of 
the mucosa, detritus, etc., also nephrolithiasis (which, however, is 
always accompanied by colic, and, lastly, floating kidney, if its move- 
ments cause a bending of the ureter. During the occlusion of the 
ureter there is hydronephrosis, and the flood of urine makes its appear- 
ance as soon as the obstacle disappears.^ 

Finally, we must briefly refer to some drinks which temporarily 
increase the amount of the urine, as coffee, beer, and wine, which 
increase the quantity of urine more than the amount of water rep- 
resented. Likewise, there are to be mentioned certain medicines 
which have the same effect, partly in that they increase the blood- 
pressure by affecting the action of the heart, partly in that they stim- 
ulate the secreting action of the kidneys. 

In the above pathological conditions, where we do not have a 
removal from the organism of water that has accumulated there, 
the polyuria must, of course, be made up by imbibing an increased 
amount of drink (^polydipsia). Whether we have the increased thirst 
from increased loss of water, or whether the polyuria is the result of 
the polydipsia, is not entirely clear, especially in many cases of dia- 
betes insipidus. In diabetes mellitus the polyuria is probably only 
a purely secondary result of the polydipsia, which, in turn, is to be 
regarded as the consequence of the glukemia (Cohnheim). 

Diminished amount of urine, under some circumstances even to 
the extent of not passing any {anuria), occurs — 

From diminution in the secretion of urine — 

1. In the loss of water in other ways : in severe sweating'' in any 
kind of severe diarrhea, particularly in Asiatic cholera, where for days 
together there is continuous anuria. Thus, also, during the formation 
of a pleuritic or peritoneal exudate, where fever is also to be taken into 
account as a cause. 

2. In fever, and largely in consequence of the loss of water in other 

1 See under Specific Gravity and Sugar in the Urine. ^ See page 361. 

3 See page 358. * See also Normal Urine. 



368 SPECIAL DIAGNOSIS. 

ways, by increased perspiration and tlie greater loss of water by the 
lungs. 

3. By reduced blood-pressiire resulting from the diminished w^ork 
of the heart : hence in diseases of the heart-muscle ; incompensa- 
tion in valvular disease ; in weakening of the hypertrophic heart of 
contracted kidney ; in emphysema ; in all the diseases, frequently 
mentioned, which harmfully affect the action of the heart. In these 
conditions the amount of the urine is the chief means of forming a 
judgment of the course of the disease and furnishes the indications 
for treatment. 

4. In acute, siibacitte, and chronic nepJiritis, except contracted kid- 
ney (regarding which, see also above under 3). In these diseases also 
the amount of the urine is a symptom which indicates the severity of 
the case. In acute nephritis, not infrequently, for a time there is anuria. 

5. From suppression of urinary secretion due to nervous causes, 
especially in a still indistinct reflex way in trauma, as from operations, 
affecting the abdomen. 

Also, there may be a less quantity of urine from difficulty in mic- 
turition : from a very narrow stricture of the urethra (surgery) ; from 
retention in the bladder ; from obstruction in the ureters. In regard 
to the latter, when one kidney is cut off the other generally vicariously 
performs the work of both ; but there may also be anuria when one 
ureter is closed, as from stone in the kidney, and this, in fact, from a 
kind of reflex suppression in the other kidney (" shock "). 

The great zeal in using the catheter in recent times has given us as 
a result, among other things, the knowledge of the fact that in health 
with every urination the bladder is completely emptied, even to a few 
drops. If a certain amount of urine remains in the bladder {residual 
urine), there is a pathological cause for it. This may be a purely 
mechanical hindrance to the emptying of the bladder, as stricture, 
hypertrophy of the prostate, urinary calculi ; or it may result from the 
mechanical hindrance — atony of the bladder ; or there may be primary 
nervous paresis of the detrusor, as occurs in tabes and in all diseases 
of the lumbar cord. The amount of residual urine is said to be toler- 
ably constant ; it is measured by having the patient pass his urine and 
then use the catheter immediately afterward. 

Color and Transparency of the Urine in Disease. — Color. — 
Primarily, the color varies according to the degree of concentration, in 
the same way as in normal urine ; and as in health, so also in general 
in disease, it stands in a certain relation to the amount of the urine : 
the greater the amount the clearer the urine. But, like the variations 
of quantity from the average, the changes in the color of the urine 
(apart also from unusual colors) ^ are also much more significant in 
disease than is the case in normal urine. The scale of colors of the 
urine passes from the almost colorless to the straw-yellow, reddish, 
red-brown, even brown-black. It is not necessary to have a very exact 
determination of the color of the urine by comparing it with those of 
a table of colors, as was proposed by Vogel, because it could only 
have a value in determining the degree of concentration, and generally 
for this the specific gravity is much more exact.^ 

1 See next page. ^ See Specific Gravity. 



EXAMINATION OF THE URINARY APPARATUS. 369 

Patients with cirrhosis (N. B., without icterus) ^ sometimes pass urine 
that, in proportion to its amount, is very dark. Anemic (chlorotic) per- 
sons, on the other hand, often pass remarkably clear urine. In fever 
the urine is relatively dark — reddish or brownish-red (urobilin).^ 

In diabetes mellitits there is a peculiarity in the very striking con- 
tradiction between the clear color and great amount of the urine on 
the one side, and its high specific gravity upon the other, which is of 
diagnostic importance. 

As special pigments of the urine, the following are to be men- 
tioned : 

1. Color due to the increase in the normal pigments. Two of these 
come into consideration here : 

Indican, occurring in increased amount, may sometimes give to the 
urine a bluish or bluish-black color, if it has been decomposed in the 
urinary passages and changed into indigo-blue ; but very often we do 
not recognize that the urine contains more indican, because indigo has 
not yet been formed. Hence, when there is a suspicion of indican, or 
if we wish to make use of its possible presence for the purposes of 
diagnosis, even when the urine appears to be perfectly normal, we 
must examine it with reference to this substance. When urine con- 
taining indican has been standing for some hours, it can generally be 
recognized by the bluish shimmer of the residuum from the drops of 
urine from the upper part of the urine-glass sprinkled and spread out 
as thin as possible, and sometimes, also, by a bluish film upon the 
surface of the urine. Besides, all of the urine is sometimes blackish- 
blue, and this is most markedly the case when the urine putrefies.^ 

Indicanurca — that is, increase of the indican — occurs : when there 
is accumulation of the intestinal contents, especially of the contents of 
the small intestine, hence in occlusion of the intestine from any cause, 
as peritonitis or obstinate obstipation ; likewise, in all forms of severe 
cachexia, as well as in Asiatic cholera ; lastly, in individual cases in 
health. Children are generally inclined to an abundant excretion of 
indican. 

Urobilin, if it exist in considerable quantity in the urine, colors it a 
decided red or brownish-red. The foam of the urine sometimes looks 
yellowish-red or yellowish-brown. Moderate quantities only indis- 
tinctly discolor the urine. While there is only a small quantity of it 
in health, it is abundant in febrile diseases, especially in alcoholics, and 
where there is at any time resorption of large effusions of blood, and 
in the most varied affections of the liver (as a first sign of alcoholic cir- 
rhosis, in the first stage of congestion of the liver — Hayem). When 
there is a marked separation of it which continues for some time, a 
brownish discoloration of the skin is observed in the so-called urobilin- 
ictencs, though there is still dispute as to its nature (compare what has 
already been said on page 42). 

Proof of the increase of indican : The following reaction (v. Jaffe) 
establishes the presence of indican in increased amount, because it does 
not operate in the presence of the small quantity found in normal urine. 
We mix equal parts of urine and fuming hydrochloric acid in a re- 
agent glass ; into this we drop two to three, or at most four, drops of 

1 See below. ^ For its Chemical Reaction, see next page. 

24 



3/0 SPECIAL DIAGNOSIS. 

a concentrated solution of chlorinated lime : immediately, or after a 
few seconds, there is formed just beneath the surface a blue-black 
cloud — indigo-blue. By stirring the solution of lime in the urine we 
obtain, according to the quantity of indigo formed, a more or less 
dark coloration of the whole fluid. If, then, we add a few drops of 
chloroform and agitate (not shake) the reagent-glass several times, we 
have the blue color at the bottom from the settling of the chloroform. 
Though there may be an increase of indican, it will not be shown by 
the reaction if too much chlorinated Hme has been added, because the 
indican is then oxidized into indigo-white. 

Obermayer has lately suggested an indican test which seems to be 
more distinct and reliable than Jaffe's. It is also somewhat more cir- 
cumstantial. To the urine 20 per cent, of sugar of lead is added ; then 
filter ; to the filtrate add an equal volume of fuming hydrochloric acid 
containing 0.4 per cent, of chlorid of iron. Shake the mixture, when 
the reaction will develop in two to three minutes. After this apply the 
chloroform as above. 

Proof of urobilin, i. Spectroscopic : Absorption bands in green- 
blue, between Frauenhofer's lines b and F (sometimes it is necessary 
to dilute the urine with water, in order to be able to make the exam- 
ination). Tissier has lately recommended to superimpose the urine 
with water. The urobilin rapidly diffuses into the water, and in this 
it is easily recognized by the spectroscope. 2. Chemical : We add 
ammonia to the reddish urine in the reagent-glass. If there is much 
urobilin, it gradually becomes a clear green ; it is then filtered ; and, 
sometimes, upon the addition of a few drops of a watery solution of 
chlorid of zinc, there appears the rose-red-greenish fluorescence that is 
peculiar to urobilin. 

2. Discoloration of the urine from the presence of the coloring-matter of 
the blood, and of the bile. Coloring matter of the blood colors the urine 
variously according to the amount that is mixed with the urine, also 
whether it is fresh or has been changed, and according to the original 
color (concentration) of the urine : flesh-red or blood-red with greenish 
shimmer with the light passing through it, corresponding to the 
dichrotic behavior of the blood; or an untransparent brown, even 
blackish-brown. Frequently the bloody color is easily recognized ; 
but, generally, the reaction-test for blood coloring matter is neces- 
sary.^ 

Coloring matter of blood occurs in the urine : i. In hematuria. Its 
occurrence here is circumstantially described in the section on admix- 
ture of blood with the urine in connection with Urinary Sediments, 
on page 375. 2. In hemoglobinuria. In this condition the hemoglobin 
is found entirely dissolved or in granular lumps, but no red blood-cor- 
puscles, or very few, are found in the urine. This results from hemo- 
globinemia (see pages 233 and 235), and this condition may arise from 
very different causes : from poisons (chlorate of potash, mineral acids, 
arsenical solutions, pyrogallic acid, naphthol, poison of the edible 
mushroom, helvella esculeitta ; after transfusion of animal blood (as 
of lamb's blood) ; in infectious diseases (as scarlet fever, abdominal 
typhus [typhoid fever], malaria, syphilis) ; after extensive burns ; lastly, 

' See p. 399. 



EXAMINATION OF THE URINARY APPARATUS. 37 1 

we have to mention a form of hemoglobinuria which occurs as an 
independent disease — paroxysmal henioglobmttria. 

Colormg matter of the bile exists tJi the twine in icterus (icteric 
urine). Such urine is most frequently a beer-brown, sometimes brown- 
green, or even black. If the urine of icterus, as is very seldom the 
case, is very thin, then it may have a golden-reddish tone. The foam 
that forms when it is shaken is then highly characteristic : from clear 
to dark yellow, green-yellow, even brownish. Regarding the chemical 
tests for bile coloring matter, and more particularly regarding its pres- 
ence and that of the bile acids in the urine, see section on Coloring 
Matter of the Bile, page 363. 

3. Discoloration of the urine from medicines. It is very important 
to recognize these changes in color, so that one may be on guard 
against deception by confounding them with the coloring matter of 
the bile and the blood. 

The chrysophanic acid contained in rhubarb and senna passes off by 
the urine. It colors the urine sHghtly, making it at most a little brown- 
ish, if normally acid ; but if alkahne, or is made so, then it becomes a 
purplish-red. 

After taking logwood, alkaline urine also becomes reddish or violet. 

Santonin colors the urine yellow or greenish-yellow, with a yellow 
foam ; upon the addition of an alkah the color changes to red. Picric 
acid makes the urine yellow, but there is no change in color after 
changing the reaction. 

Carbolic acid, naphthalin, creasote, and other coal-tar preparations, 
as well as the infusion of the leaves of uvae ursi (arbutin), produce a 
greenish or greenish-black color of urine. 

Brownish or blackish discoloration of the urine after standing for 
some time in the air is observed in patients with melanotic tumors, 
because the pigment which forms the coloring matter of the blood in 
those tumors passes off by the urine. A similar behavior of the urine 
is found in the presence of an abnormal amount of pyrocatechin, an 
extremely rare occurrence. 

Transparency of the Urine. — A loss of transparency by turbid- 
ness may take place even in normal urine when it has been allowed 
to stand.^ Likewise a more marked cloudiness (nubecula) occurs in 
normal urine from the increase of the mucin-like substance. This 
also occurs in diseases of the urinary apparatus, particularly of the 
urinary passages. Urine that is turbid when passed is always patho- 
logical. This is the case : first of all, in nephritis, in consequence of the 
presence of organized constituents ; in all diseases of the urinary pas- 
sages, for the same reason (here particularly on account of mucus) ; 
but especially in severe cystitis, because the urine in this condition is 
alkaline when it is passed (alkaline fermentation in the bladder), and 
hence, besides the organic constituents, contains a deposit of phosphates. 
Admixture of blood and pus always makes the urine turbid to some 
extent. The most striking and, at the same time, the rarest kind of 
turbidness is that caused by fat in the urine — chyluria. Here the urine 
is milky, as if mixed with pus {galaciuria) from the emulsified fat ; or it 
contains large drops of fat or fat-bubbles swimming upon its surface 

1 See p. 363. 



372 SPECIAL DIAGNOSIS. 

(lipuria). By shaking the urine up with ether it becomes clear. But 
when it is allowed to stand, part of the fat settles as a sediment, and 
part forms a cream-like layer on top.^ 

The Specific Gravity of the Urine in Disease.— The specific 
gravity of the urine may vary from a little over looo to over 1060 (in 
diabetes mellitus). Apart from certain special admixtures (we mean 
particularly sugar, which increases the specific gravity without changing 
the color, and the special pigmentary admixtures, which, on the other 
hand, darken the color without essentially adding to the specific gravity), 
almost always in disease, as in health, a scanty, dark urine has a high 
specific gravity ; an abundant, clear urine, a low specific gravity. Ac- 
cording to Haeser and Neubauer, from the specific gravity we can 
obtain an approximation to the amount of solid constituents of the 
urine by multiplying the last two figures of the specific gravity by 2.33. 
This product represents the quantity of sohd constituents in lOOO 
grams of urine. If we have 1 200 grams of urine with a specific 
gravity of 1021, then lOOO grams of this contains 21 X 2.33 = 48.93 
grams of solids, and the whole amount = 58.7 grams. But not much 
has been said regarding the change of material upon which it chiefly 
depends, because the different solid constituents of the urine have very 
different specific gravity, particularly urea, which, as compared with 
sodium chlorid, is as 2 : 3. Hence, we can never draw definite 
conclusions from the specific gravity alone, and even where we can 
exactly determine the solids, as by examining the various material 
changes, the quantitative determination of the 'urea or of the nitrogen 
is indispensably necessary. 

The chief value in the determination of the specific gravity with 
reference to diagnosis consists in the following : 

1. High specific gravity with clear and abundant urine points to 
diabetes mellitus. We may even say that a specific gravity of 1040 
and over, the urine being clear, can only be caused by sugar, and 
hence is pathognomonic of diabetes. 

2. Repeated or continued examination of the urine in general en- 
gorgement is of value, because this, as well as the quantity of the urine, 
measures the labor of the heart. 

It is not unimportant to know further — 

3. A low specific gravity, when there is a small amount of urine 
which is often high colored, occurs in nephritis from diminished excre- 
tions of urea, also in severe diarrhea and vomiting. 

Reaction of Urine in Disease. — For the reasons previously 
given ^ the reaction of the urine is reliable only a short time after it has 
been passed. 

Neutral or alkaline reaction of the urine is met with in sickness — 

1. Under the same conditions that make it neutral or alkaline in 
health. 

2. When there is resorption of transudates and exudates in the 
cavities of the body, also from large effusions of blood, especially in 
the pleura and peritoneum. 

3. With dilatation of the stomach, and particularly if the contents of 
the stomach must frequently be brought up, either by vomiting or arti- 

1 Further regarding Chyluria, see p. 378. ^ See p. 364. 



EXAMINATION OF THE URINARY APPARATUS. 373 

ficially. The reason given is that the blood and the organisms lose 
their acidity because free HCl is not again resorbed (?).^ 

4. Considerable admixture of blood or pus. In the cases of alkaline 
urine previously mentioned the urine is clear, or is turbid from the de- 
posit of phosphate ; it contains no bacteria or only a few. 

5. With alkaline fermentation of the urine in the bladder. This 
accompanies severe forms of cystitis. Here the urine is turbid because 
of the presence of pus-corpuscles, abundant bacteria, deposit of triple 
phosphates, urate of ammonia, carbonate and phosphate of lime and 
magnesia. Sometimes it has a peculiar urinous smell, and is pungent 
from the free ammonia. By this latter a strip of red litmus-paper, just 
held free over the fluid, is colored blue. 

Further, regarding the formed constituents of simple alkaline urine 
and that which has been the subject of alkaline fermentation, see under 
Sediment. 

The acidity of the urine may be determined by a simple but really 
not very accurate method : Prepare a 10 per cent, solution of caustic 
soda (i of soda to 9 of distilled water), and pour this from a burette 
into the urine until a piece of very sensitive litmus becomes blue : i 
c.cm. of the soda solution corresponds to 0.0063 of oxaHc acid. 

Works upon analysis of the urine teach the more exact methods. 

Pathological Odor of the Urine. — Here we must mention as 
worthy of recognition the pathological departures from the odor of nor- 
mal urine. A urinous, more or less pungent, ammoniacal odor in cases 
of severe cystitis shows ammoniacal fermentation in the urine that is 
passed. Then there is the feculent odor when the urine is mixed with 
feces, whether the admixture takes place after the urme is passed,-^ or 
whether it has taken place from communication between the bladder 
and the intestine, with discharge into the bladder. 

The most notable, and at the same time diagnostically important, 
odor of the urine is the fruity {apple-odor), or like chloroform. The 
substance which has this peculiar odor seems to be acetone (Fetters) 
[compare what is said later regarding Acetone]. The urine which has 
this odor upon the addition of chlorid of iron sometimes gives a bur- 
gundy-red reaction (" chlorid-of-iron reaction," Gerhardt), which shows 
the presence of aceto-acetic acid.^ Usually the odor of apples is even 
more noticeable in the breath of the patient than in the urine, and it 
may be noticed in the breath alone. 

The apple-odor is observed in individual cases of diabetes inellitiis. 
It especially occurs in diabetic coma or as the precursor of this condi- 
tion, but it also exists — and, indeed, often for a long time — without the 
occurrence of coma. 

Unusual odors may be imparted to the urine by medicines : after 
taking turpentine, violet odor ; after cubebs and copaiva, the aromatic 
odor of these drugs. 

Foul, albuminous urine, but especially urine that contains pus, de- 
velops, as the result of certain organisms, sulphuretted hydrogen — 
hydrothionic urine. Sometimes this fermentation, with the develop- 
ment of sulphuretted hydrogen, seems to take place in the bladder 

^ See above, under Reaction of Normal Urine, p. 364. 2 g^g p -^50. 

3 See further, p. 407. 



374 SPECIAL DIAGNOSIS. 

(cystitis). On the other hand, if the urine when first passed is clear, 
and upon being promptly examined is found to contain sulphuretted 
hydrogen, it is probable that there has been resorption of SHg into 
the blood or into the bladder from the intestine, or from a depot of pus 
in the neighborhood of the bladder ; under which circumstances the 
general symptoms of poisoning have occasionally been observed. 

Urinary Sediments. — We are to call to mind the sediments, pre- 
viously mentioned, which may occur in normal urine. On the other 
hand, these same sediments may sometimes be observed as pathological 
signs, as is shown in what follows : 

All formed constituents which separate when the urine is allowed 
to stand are reckoned as " sediments," whether they can be recognized 
with the naked eye or only under the microscope, or whether they are 
organized or are really " deposits." As previously mentioned, in order 
to examine the sediment it is desirable carefully to pour off from the 
vessel containing the urine the upper part ; the lower turbid or already 
settled portion is to be put into a glass with a pointed bottom, and 
again allowed to settle. Then follows the examination with the naked 
eye and with the microscope. For the latter we take up some of the sedi- 
ment with a pipette closed by one finger placed upon the upper end and 
introducing it to the bottom of the pointed glass, when it is to be 
opened again for a moment ; then it is withdrawn and carefully wiped 
off and a drop of its contents allowed to flow upon an object-glass. 
[A slide with a depression in the center making a shallow cell is very 
convenient, since a larger drop can be examined at each time.] Upon 
this we place a glass cover, and examine it with a magnifying power 
of about 400 diameters. If the sediment is very scanty, we are to 
focus the microscope so as first to examine the edge of the covering- 
glass. It may happen that the sediment is so scanty that we cannot 
see anything at the bottom of the glass with the naked eye, but by 
carefully removing a drop from the bottom of the glass and placing it 
under the microscope we may possibly make out formed constituents, 
as a few casts (contracted kidney). 

Steiibeck's Sedimentator^ [Centrifuge]. — This instrument is of extra- 
ordinary advantage for quickly separating all kinds of soHd particles 
which are suspended in liquids. The principle is very simple : A por- 
tion of the liquid is centrifugated for a few minutes in small tubes 
similar to test-tubes. All the solid constituents are assembled at the 
bottom of the tube, which is somewhat narrowed — crystals, cells, red 
blood-corpuscles, micro-organisms, casts, etc. The method is applica- 
ble to all liquids. 

It is necessary to color the urinary preparations only when examin- 
ing for certain micro-organisms.^ 

Organic sediments (epithelia, white blood-corpuscles, casts) may be 
stained with osmic acid, which makes them visible, and also shows fatty 
degeneration if it exists. One or two drops of the sediment are put 
into a I per cent, solution of osmic acid, shaken, allowed to settle, and 
the sediment examined. The fat is stained black, brown-black, or 
gray. 

1 Instruments of this character are now made everywhere, and are readily obtainable; 

2 See p. 383 ff. 



EXAMINATION OF THE URINARY APPARATUS. 375 

I. SEDIMENTS OF ORGANIC BODIES OR THEIR DIRECT PRODUCTS. 

Mucus. — Physiologically, this exists only in small quantities.^ It 
is increased in all diseases of the urinary passages, but especially in 
cystitis, and also in fever. 

Some mucous forms are characteristic : in the form of minute 
roundish floccules, the size of a millet-seed or the head of a pin, they 
are tolerably characteristic of mild cystitis. Under the microscope 
they show white blood-corpuscles lying closely to one another, and 
they are apparently conglomerations of white corpuscles. 

In the form of threads i to 2 cm. long — gonorrheal threads — which 
are sometimes more purely mucous in character, and, again, contain 
abundant pus-corpuscles : they occur in chronic gonorrhea or as the 
residuum of a past attack. 

Finally, we find microscopical mucous threads, cylindroids (see Fig. 
137, page IJ^), which may be confounded by the inexperienced with 
tube-casts. They are found in nephritis by the side of the casts in cys- 
titis but also in health. They are distinguished from urinary casts by 
their usually being of considerable length, their mucus-thread texture, 
their very varying thickness (as fine as threads, especially at the end), 
and their tape-like appearance. The nature and significance of these 
formations have not yet been satisfactorily elucidated. They are found in 
diseases of the urinary passages, the kidneys being healthy, as in cystitis 
and pyelitis, but besides they occur in some cases of nephritis in 
company with casts. We have found them in slight acute hemorrhagic 
and non-hemorrhagic nephritis, and several times in greater numbers 
than the casts. At present we cannot regard as successful the attempt 
to classify these formations according to their renal or non-renal origin. 

Chemical proof of muctis in solution : The addition of acetic acid 
makes a flocculent precipitate, which is not again dissolved by an 
excess of acid, nor is it again dissolved by heat, as is the case with a 
precipitate of urates produced by acetic acid. 

In women mistakes may arise from the admixture of vaginal mucus 
with the urine. 

Blood or Red Blood-corpuscles. — The appearance of the urine 
varies very remarkably in hematuria. Sometimes there is a consider- 
able bloody sediment, not infrequently partly coagulated ; again, only 
a fine deposit of red blood-corpuscles spread out evenly ; and lastly, 
sometimes a more brown-red, clear, or dark-brownish sediment. The 
red blood-corpuscles may be so scanty as to escape detection with the 
naked eye. This distinction pertains to the amount of the blood, and 
its having been for a longer or shorter time in the urine — that is, with 
reference to the location of the hemorrhage. (Regarding the color of 
the urine, see page 368.) 

Hematuria occurs — 

ia) In diseases of the kidneys — that is to say, in acute and chronic 
hemorrhagic nephritis, in embolic hemorrhagic infarction of the kidney 
(valvular disease of the heart), in septic hemorrhage of the kidney 
(acute endocarditis), in marked engorgement of the kidney, with new 
formations, and, lastly, in injuries to the kidney. 

1 See p. 363. 



37^ 



SPECIAL DIAGNOSIS. 



(b) In certain diseases of the urinary passages, and also of the pel- 
vis of the kidney (nephrolithiasis, tumors), of the bladder (severe cys- 
titis, tumors, stone), of the urethra (gon- 
orrhea), and with parasites of the urinary 
canal.^ 

Moreover, hematuria has symptomatic 
significance for recognizing diseases of 
other kinds. Thus it occurs in scorbutus, 
morbus Werlhofii, hemophilia, and, lastly, 
in the rare hemorrhages of the kidney or 
urinary tract that are due to leukemia. 

From the appearance of the sediment 
and the way it is passed a conclusion with 
reference to the location of the hemorrhage 
and the kind of disease will be made from 
the following points of view: 
• A small amount of blood — or at least a 
not too abundant quantity of blood — uni- 
formly mixed with the urine, the color of 
the blood being retained or, more fre- 
quently, changed into a brownish color, 
points to a hemorrhage of the kidney. 
That this is its source can be more cer- 
tainly proved by the microscope showing 
blood-casts.^ Where there is renal hemor- 
rhage the blood-corpuscles are always 
more or less discolored, as rings or shad- 
ows. Cells and casts, if present, are stained 
brown by the coloring matter of the blood. 
A brown color of the sediment and of the 
urine indicates acute hemorrhagic nephri- 
tis. The sudden occurrence of bloody 
urine, with valvular disease of the heart, 
points to renal infarction. Individual red 
blood-corpuscles occur in very concen- 
trated urine in renal engorgement. 

In hemorrhage of the pelvis of the kid- 
ney, especially that caused by stone, the 
urine usually alternates between being bloody and free from blood, 
and this either because there are temporary hemorrhages or because 
the ureter of the diseased side is for the time being stopped, and then 
the urine that is passed only comes from the sound side. The blood 
may for a time escape very freely ; in rare cases it may be passed in the 
form of vermiform coagula (casts of the ureter), which give great pain 
as they are passed. 

Cystic hemorrhages, especially in villous tumors, may be so free as 
to be fatal. The urine is not intimately mixed with blood, especially 
if the patient lies quietly in bed ; at first there is little or no blood at 
each urination ; but then, again, pure blood is sometimes passed. On 
the other hand, in hemorrhage from the urethra blood comes only at 




Fig. 137.- 



-Cylindroids (see p. 375) 
(v. Jaksch). 



I See p. 382. 



See p. 382. 



» 



EXAMINATION OF THE URINARY APPARATUS. 377 

the beginning of the urination. Here sometimes there is an escape of 
blood between the urinations. Works upon surgery treat more at 
length of hemorrhages of the bladder and urethra. 

Microscopical Examination. — In every respect this is the most valu- 
able method for recognizing hematuria, especially from the following 
points of view : i. Because the separate red blood-corpuscles can be 
discovered where neither the fluid portion of the urine nor the sediment 
shows the color of blood, and where, also, the fluid portion does not 
show the reaction of the blood-pigment.^ 2. Because it alone estab- 
lishes the differential diagnosis between hematuria and hemoglobinuria. 
3. Because, from the condition of the red blood-corpuscles, from the 
presence of possible blood-casts,^ we can sometimes determine that 
there is renal hemorrhage. 

In hematuria we find more or less abundance of red corpuscles. 
In decided hemorrhage, especially from the lower portion of the 
urinary tract, these are only slightly changed. If retained for some 
time in the urine, and particularly if they are scanty, as in renal hem- 
orrhage, they are smaller, have granular contents, or are more or less 
markedly discolored. If they are very pale, then we have the so-called 
rings. If there are no red blood-corpuscles in a urine that is bloody 
and certainly contains hemoglobin,^ or if they are very scanty in a 
urine that contains a good deal of hemoglobin, then we have hemo- 
globinuria.^ 

Besides red blood-corpuscles, we frequently find in the sediment, 
according to the disease present, still other formed constituents ; in 
cystitis, first of all, white blood-corpuscles, phosphate crystals ; in 
nephritis, casts and white blood-corpuscles. A considerable amount 
of blood in the urine makes it somewhat albuminous. 

With women we must remember the possibility of being deceived 
by the menstrual blood. 

Hemoglobin. — In hemoglobinuria there is usually a brown or 
brown-black sediment, which consists of brown flakes and fine granular 
detritus. A few red blood-corpuscles are likewise found. If casts 
and epithelium are present, they are often colored brown. 

Pus; White Blood-corpuscles. — It is rare that a considerable 
amount of pus is passed by the urethra. It sometimes appears in 
severe cystitis, and in the highest degree, when a neighboring depot 
of pus breaks into the urinary passages, either into the pelvis of the 
kidney or into the bladder. In the first instance, perinephritic abscess, 
and in the second pericystic, parametritic, perityphlitic abscesses, are 
the conditions which may occasionally manifest themselves by sudden 
pyuria. The pyuria may quickly pass away, but cystitis may follow. 

Admixtures of pus — i. e. sediment of white blood-corpuscles of greater 
or less amount — may be caused by inflammation of the mucosa of the 
urinary passages ; that is, by pyelitis, ureteritis, cystitis, urethritis, or 
by nephritis. In the latter case they are never very abundant. 

Pus-sediment at first sight is yellowish, purulent, lighter, or wholly 
white in appearance. In pyelitis and cystitis, if the sediment is scanty, 
what is seen are mostly small distinct balls, smaller than millet- 

^ See p. 4CX). '-^ See Casts, p. 382. 

^ See Examination of the Dissolved Portion, p. 370. ^ See this. 



3/8 SPECIAL DIAGNOSIS. 

grains, which under the microscope are found to be globular conglom- 
erates of pus-corpuscles. They are far too large to possibly come 
from the kidneys, and hence they point positively to the urethral 
passages. 

In nephritis the pus-sediment is often finely powdered, loose, and 
may suggest a sediment of phosphates. This appears exceptionally 
also in chronic cystitis. In inflammation of the urinary passages the 
sediment generally becomes a peculiar compact jelly from the mucus it 
contains ; in alkaline urine it is due to a mucus-like swelling of the 
white blood-corpuscles.^ 

The microscopical examination shows the white blood-corpuscles 
more or less changed according to their amount, the length of time 
they have been in the urine, and the reaction of the latter. In alka- 
line urine they are very clear and much swollen. Of the diseases of 
the kidneys, acute hemorrhagic nephritis and subchronic (chronic 
parenchymatous) nephritis produce a relatively abundant amount of 
pus-corpuscles. Senator says that among the pus-corpuscles of 
nephritis there are only a few eosinophile clear leukocytes, but leuko- 
cytes with one or more nuclei (those with one nucleus are often very 
much more numerous). The mononuclear cells resemble in part 
lymphocytes, but the body of the cell is large, so that they look like 
young epithelia. 

To a slight degree pus makes the urine albuminous ; a considerable 
amount of albumin in the urine is always due to renal albuminuria. 
When the quantity of albumin in the urine is slight, the question may 
arise whether we have nephritis either as a separate disease or as a 
complication of cystitis or pyelitis. This can only be answered by the 
infallible sign of nephritis — that is, casts in the urine. 

Pat-drops. — The fat accompanying chyluria may, as was pre- 
viously mentioned, exist in the urine as a sediment, but also as a cream- 
like or swimming layer or in the form of large drops. " We must re- 
member that it may be due to impurities, as the use of an oiled 
catheter, etc. The microscope shows minute particles of fat or large 
drops which markedly refract the light. In the first case the fatty 
character of the sediment may be most quickly recognized by the 
grease-spot formed upon paper by the sediment. We may also shake 
it up with ether, and then allow the ether to escape by evaporation. 

The occurrence of fat-drops free and attached to casts, adipose, 
white blood-corpuscles, is very important in diagnosing large white 
kidney. 

^j^pithelium. — We find in the urine the epithelium of the urinary 
passages and the epithelium of the renal urinary channels [urinary 
tubules]. In addition, in women very frequently, but especially when 
there is leukorrhea, we have flat epithelium from the vulva. The 
epithelial cells in transition are everywhere very similar. But renal 
epithelium is usually easily recognized as such. 

While in normal urine only individual flat epithelial, and sometimes 
caudate, cells occur, in inflammation of the urinary passages we meet a 
large quantity of the three species of cells named. Usually they are 
well preserved. It is misleading to form a conclusion from the kind 

^ See above. 



EXAMINATION OF THE URINARY APPARATUS, 379 

of cells as to the location of the inflammation (especially whether of 
the pelvis of the kidney or of the bladder). The vulva being excluded, 
a large quantity of flat epithelium points to the bladder. Abundant 
caudate, but especially overlapping, " tile-like," roundish cells with 
large nuclei were formerly often regarded as characteristic of inflam- 
mation of the pelvis of the kidney ; but more recently this view has 
come into discredit. 

Renal epithelia occur in considerable numbers only in affections of 
the kidney, and especially in nephritis. If their form is well preserved, 
they are recognized without difficulty as polygonal or round-cornered 
cells of peculiarly sharp contour, with large oval nuclei and a decidedly 
granular, often yellowish-looking, protoplasm. They are small — not 
larger than white blood-corpuscles, sometimes smaller. In acute 
hemorrhagic nephritis they are often coarsely granular, brownish in 
color ; in the large white (butter) kidney, but sometimes also in the 
first disease, we not infrequently see them in all stages of fatty 
degeneration. 




Fig. 138. — Epithelium from the urine. 

a, b, epithelium from the bladder, from the pelvis of the kidney ; c, caudate epithelium (pelvis of the kidney ?) ; 
d, renal epithelium, partly changed into fat. 

Regarding cylindrical epithelium, see under Casts. 

Shreds of Tissue. — Shreds of connective tissue and " caseous 
crumbs " are found in tuberculosis of the urinary apparatus. 

Particles of carcinomatous tissue are separated in carcinoma of the 
kidney, but have been more frequently observed in carcinoma villosum 
of the bladder. Only particles which distinctly show the structure of 
carcinomatous tissue are of importance here. Single, or also several 
pretended '' cancer-cells " lying close to one another, have no diagnostic 
value. 

Spermatozoa. — After every discharge of semen these are seen in 
the urine. Hence they are not unimportant for detecting masturbation. 
They also occur in spermatorrhea. Lastly, sometimes they are found 
after epileptic attacks ; also now and then with severe diseases of all 
kinds, as in typhoid-fever patients. 

Casts. — These important form-elements of the urine were discov- 
ered by Henle in 1842. As we have mentioned before, occasionally 
isolated casts may be found in the centrifugated urine of healthy per- 
sons without there being simultaneously the least trace of albumin 
chemically demonstrable. Casts have also been found in the albumin- 



380 SPECIAL DIAGNOSIS. 

less urine of persons suffering from disturbances of circulation (Radom- 
yski), also in icterus — particularly frequent, however, in tuberculous 
patients. Moreover, casts of a peculiar nature have been observed in 
the urine of diabetic patients before the beginning, or during the 
onset, of coma diabeticum (Kiilz and Aldehoff). But, apart from these 
particular cases, casts in the urine are a phenomenon accompanying 
renal albiiniiniiria. 

It is said that from the occurrence of icteric casts we may suspect 
the presence of biliary acids in the urine. They are intensely colored 
by biliary pigment. 

We concern ourselves only with the occurrence of casts with albu- 
minuria. By their presence these not only permit a conclusion that 
there is a disease of the kidneys which causes albuminuria, but by their 
quantity and character also enable us to diagnose the exact nature of 
the disease. Regarding their numbers, the casts are scanty, and then 
usually hyaline,^ in engorgement of the kidneys, in fever, in physiologi- 
cal albuminuria ; and, lastly, they are temporarily present in contracted 
and amyloid kidney. There is often here a sediment which is scarcely 
or not at all visible. In making a preparation we must, with the great- 
est care, take a few drops from the bottom of the urine-glass and exam- 
ine the preparation with great thoroughness. If the hyaline casts are 
scanty, it greatly facilitates finding them to stain any that may be 
present by the addition of a drop of Lugol's solution or gentian-violet 
solution placed upon the edge of the cover-glass. Casts are very 
abundant in acute, and frequently also in chronic, nephritis. In these 
diseases they may form the principal portion of a tolerably abundant 
sediment. 

Variation in the quantity of the casts is to be observed in all the 
diseases named. Sometimes, after a period of stagnation, it seems as if 
the casts are passed in greater abundance. This is not very rare in 
amyloid nephritis, also in attacks of acute nephritis. 

In size and form the casts vary greatly. We will speak further 
regarding this. 

As to their nature, we distinguish the following kinds of casts : 

Hyaline Casts. — These are of great variety as to length and 
breadth ; sometimes not so broad as a white blood-corpuscle (thin 
hyahne casts), and, again, five or six times as broad (thick or medium 
casts). In length they may be as much as i mm. They are homo- 
geneous and clear as water, with a very fine outline, hence often very 
dif^cult to see ; the ends look as if broken off, rounded, or even 
clubbed. For aggregation of substances within them, see below. 
They occur in company with other forms in all diseases of the kidney. 
Exclusively hyaline casts occur most frequently in contracted and amy- 
loid kidney, also in fever and with [renal] engorgement. 

A special kind of hyaline casts are the waxy, so named from their 
dull luster and usually yellowish color. Sometimes they show the amy- 
loid reaction with iodin and iodid of potassium — brown, then violet with 
sulphuric acid. We cannot form a conclusion from them as to the 
nature of the disease of the kidney ; certainly they are not pathogno- 
monic of amyloid kidney. 

^ See below. 



EXAMINATION OF THE URINARY APPARATUS. 



381 



Additions to the hyaline and also to the waxy casts frequently occur 
in the form of red and white blood-corpuscles, renal epithelium, crystals, 
granular masses, which in turn may show 
urates, phosphates, albuminous or fat-gran- 
ules, and, lastly, bacteria. Among these 
additions those of special significance are 
red blood-corpuscles, as in hemorrhagic 
nephritis, possibly adipose renal epithelia, 
white blood-corpuscles (granular spheres), 
and free fat-granules. These adipose ele- 
ments, if abundant, are important for the 
diagnosis of large white or fatty kidney. 

In some cases of pyelonephritis we have 
seen hyaline casts which were split hke a 





Fig. 139. — Hyaline casts (narrow and tolerably broad 
ones). 



Fig. 140. — Waxy casts (v. Jaksch). 

b, a cast containing crystals of oxalate 

of lime. 



I 



pair of trousers. These might possibly have their origin in collective 
tubes (?). 

Chemical Nature and Origin of Hyaline Casts. — Much has been written 
about the chemical nature and origin of hyaline casts. They must by 
no means be considered as a phenomenon inseparably accompanying 
albuminuria, as there is an albuminuria without hyaline casts (and 
without any other casts) and hyaline casts without albuminuria. It is 
principally this circumstance which has led to the assumption that all 
casts, and particularly hyaline ones, originate in the most diverse parts 
of the urinary ducts from the epithelia of these ducts. Several reasons, 
however, are opposed to this opinion, into which we cannot here enter. 
The most valuable investigations of recent times on the nature of these 
casts have been made by Ernst. He found that in acute as well as 
in chronic nephritis hyaline casts in part gave positive results with 
Weigert's method of fibrin-staining : some were wholly stained, some 
showed a stained nucleus and an unstained stratum lying concentrically 
around the nucleus ; others, again, an unstained nucleus and a stained 
outer stratum ; finally, some had taken up the staining substance in 
single spots. Ernst thinks it possible, although not yet proved, that 
hyaline casts are originally fibrinous, and are gradually converted into 
a hyaline-like substance which no longer reacts to the stain. It is not 
yet made clear from which part of the kidney the casts originate. 

Granular Casts. — These are generally coarse or finely granular 



382 



SPECIAL DIAGNOSIS. 



hyaline casts, with additions to their contents, as above. But, espe- 
cially in acute nephritis, conglomerate casts of albumin in lumps and 
granules also occur, sometimes stained or mixed with hematoidin. 

Blood-casts are conglomerations of red blood-corpuscles held 
together by coagulation. They are important as indisputable signs of 
renal hematuria. 

Epithelial casts are either hyaline casts with the addition of renal 
epithelium (recognized by their sharp outline and distinct large nuclei) 
or they are true epithelial tubes. In both cases they have the same 
significance — the free desquamation of renal epithelium, especially as it 
occurs with acute hemorrhagic nephritis. 







oo- «^ . S^'^ 
c /-ogo e:2)% 



e 




Fig. 



141. — Granular casts 
(v. Jaksch). 



Fig. 142. — Red blood-corpuscles, 
partly as "rings" and cast of red 
blood-corpuscles (Eichhorst). 



Fig. 143.— Epithelial 
cast (v. Jaksch). 



Casts of lumps of hemoglobin in hemoglobinuria, urate casts in the 
newly-born (uric-acid infarction in connection with ammonium urate), 
and casts of bacteria in pyemia (?) are very rare occurrences. 

We may confound casts with cylindroids,^ also with threads of linen 
or other adventitious materials in the urine. Cleanliness and practice 
in examining guard one from mistake. 

Animal Parasites. — Echinococcus. — Shreds from echinococcus 
bladders, scolices, and hooks are met with in the urine if an echino- 
coccus of the kidney or from the neighborhood of the urinary apparatus 
breaks into the urinary passage. Urination is often attended with severe 
pain, especially by attacks of colic during its transit through the ureters. 
They may be preceded by anuria from obstruction of the urethra, ob- 
struction of one ureter, and " reflex " suppression of secretion upon the 
sound side (or reflex spasm of the sphincter vesicae). 

Distoma haematobium, an exotic from Egypt, located in the roots 
of the portal vein, also particularly in the plexus vesicalis, causes 
hematuria. The eggs of the parasite make their appearance in the 
urine. 

Strongylus gigas located in the pelvis of the kidney causes pyuria 
and hematuria. 

Filaria sanguinis, an exotic from the East Indies, Japan, China, and 
Australia, located in the large lymph-vessels, among other things 
causes engorgement of the lymph-vessels of the bladder: chyluria 

1 See p. 375. 



EXAMINATION OF THE URINARY APPARATUS. 383 

(and likewise galacturia^), and hematuria (peach-red urine). Besides, 
the urine contains embryo filaria, round-worms of delicate structure, 
lying in a fine sheath, with lively motion. In width they are about 
that of a red blood-corpuscle ; in length, 2 to 3 mm. 

Oxyuris vermicularis, trichomonas vaginalis (an infusorium) from the 
vagina, and, in one case under my observation, the larva of a fly, inusca 
vomitoria (!), may become mixed with the urine. 

Vegetable Parasites and Fungi. — Normal fresh urine, free from 
impurities, is not entirely free from fungi.^ A number of bacilli and 
cocci colonize in urine that has been standing for some time, of which 
those of special interest are the ones which cause alkaline fermentation, 
changing the urea into carbonate of ammonia.^ 

In cystitis the findings seem to differ according to whether there is 
alkaline fermentation or not. In cystitis without alkaline fermentation 
of the urine a series of micro-organisms may be found which are to be 
regarded in part as the exciters of the disease. Among these the prin- 
cipal ones are the bacterium coli commune and the proteus. These 
bacteria are looked upon as the exciters of the inflammation of the 
mucosa. 

The alkaline fermentation of the urine within the bladder which 
accompanies severe forms of cystitis, however, is produced by other 
micro-organisms if they enter the bladder. These are principally chain 
cocci [micrococcus urece, micrococcus urece liquefaciens^, but also certain 
bacilli (a so-called bacillus urece, Leube and others). It is the presence 
of these fungi, in addition to the ammoniacal odor, which distinguishes 
simple alkaline urine from urine that is alkaline from fermentation.* If 
these schizomycetes are very abundant, they may form the greater por- 
tion of the sediment of the urine. Besides these, of course there are 
always pus-corpuscles and vesical epithelia, and also crystal forms of 
ammonio-magnesium phosphate and of the urate of ammonia.^ 

Alkaline fermentation of urine in the bladder always signifies a 
severe form of cystitis. It is principally found in cystitis following 
severe paralysis of the bladder and following the introduction of an 
unclean catheter. 

In pyelitis, cysto-pyelitis, and cysto-py clone phritis the bacterium coli 
commune seems to play the principal part, but besides this we must 
always bear in mind here tuberculosis and gonorrhea. 

The certain demonstration of the bacterium coH commune can only 
be made by culture of urine received into steriHzed vessels, and in 
women patients it must be drawn with the catheter. 

Tubercle bacilli in the urine are an absolutely sure sign of ulcerating 
uro-genital tuberculosis. But in this disease, especially when there is 
tuberculosis of the pelvis of the kidney or of the kidney of only one 
side, the ureter of that side is temporarily or permanently stopped. If 
tubercle bacilli appear at all in the urine, they are generally abundant, 
not infrequently even in masses, and with an arrangement which reminds 
one of a pure culture. Fig. 144 exhibits an excessive development of 
this kind. In purulent urinary sediment tubercle bacilli can be demon- 
strated just as distinctly as in the sputum. In cases of persistent inflam- 
mation of the urinary tract it is well to examine for tubercle bacilli, so as 
1 See this. ^ See p. 361. ^ See p. 363. * See p. 373. ^ Compare p. 386. 



384 SPECIAL DIAGNOSIS. 

not to overlook them. Tuberculosis of the uro-genital apparatus often 
gives rise to symptoms which for a long time simulate chronic gonor- 
rhea, a simple leukorrhea, ordinary cystitis, pyelitis, hydronephrosis, 
hypertrophy of the prostate. The examination of the urine for tubercle 
bacilli should never be omitted when such conditions as have just been 
mentioned are associated with tuberculosis of other organs, as of the 
lungs, or with suspicious local phenomena (orchitis, chronic peritonitis. 




Fig. 144. — Pure culture of tubercle bacilli in the urine in tuberculosis of the genito- 
urinary apparatus. Zeiss's homogeneous immersion ^, eye-piece No. 4. Drawn with a 
camera lucida ; magnified about iioo. Author's observation. 

etc.), or when there, is anemia, emaciation, or hectic fever. Therefore, 
if there is decided anemia, wasting, and continued fever, as well as in 
cases of long-continued gleet, every purulent urinary sediment should 
be examined for tubercle bacillus. 

Gonococci (Neisser) occur in the pus of recent gonorrhea in clusters, 
in epithelial cells, and in pus-cells. They are comparatively large cocci, 
1.6 to 1.8/i long and 0.8 to 0.5// broad. They most frequently appear 
as rather compact heaps of diplococci ; sometimes an individual coccus 
is seen with a transverse band like a kind of roll. But the essential 
characteristics are, in the first place, their appearance in heaps in the 
white blood-corpuscles and then their discoloration by Gram's method. 
If stained after Gram and unstained, and then afterward stained again 
with Bismarck-brown, they even take up the latter color just the same 
as the cells do. Sometimes, particularly in the gonorrhea of women and 
in chronic gonorrhea of men also, there may be but extremely few 
gonococci, or they may be entirely absent for a time. In the latter 
case Neisser has made injections with slightly irritating substances, and 
thus produced a temporary appearance of the gonococcus in the secre- 
tion. Neisser recommends these stimulating injections as an important 
aid in diagnosis. It is best to use a watery solution of hydrargyri chlo- 
ridum corrosivum i : 10,000. As yet, we have had no personal expe- 
rience with this method. The gonococcus may easily be confounded 
with other similar cocci which occur in the urethral secretions in 
benign urethritis, and even in health. But it is settled now that the 
above-mentioned qualities belong only to the gonococcus (Neisser). 



EXAMIXATION OF THE URINARY APPARATUS. 385 

The gonococcus is to be stained with gentian-violet or methylene-blue 
or fuchsin, and then rinsed in water. 

It must not be forgotten that acute and chronic purulent urethritis 
may be caused by other micro-organisms — streptococci, diplococci, and 
tubercle bacilli — and likewise that they may be free from bacteria. 






ma - ,-., 



% 



^.*t 



• ^^ ^ ^ 



Fig. 145. — Gonococci in pus from urethra ; dry preparation. Stain : methylene-blue. 

PatJiogenic fungi zvliidi circulate in the blood, in individual cases, 
are found in the urine : thus, tubercle bacilli in acute miliary tuber- 
culosis, typhoid bacilli, equinia, erysipelas cocci in erysipelatous ne- 
phritis (Fehleisen), spirillum recurrens in complicating hemorrhage 
of the kidney (Kannenberg), pus-cocci in pyemia or endocarditis 
(Weichselbaum and others). Also, casts of micrococci are described 
in septic processes (Litten and others). 

Lastly, in cases of acute nephritis bacteria have recently been found 
in the urine and in the kidney which have been regarded by different 
authors as the specific excitants of the nephritis. As yet, these cases 
are too much isolated and too uncertain to permit us to form a definite 
conclusion. 

A small form of sarcina is found (rarely) in alkaline fermentation in 
the urine. It, as well as the other fungi named, is regarded as the 
cause of the transformation of the urea. Leptothrix buccahs occurs 
as a foreign substance, as from the preputial sac (Huber). 

The occurrence of the yeast fungus, saccharomyces, in urine con- 
taining sugar is not unimportant. Here it causes acid fermentation. 
In urine that does not contain sugar some yeast-cells are found occa- 
sionally, but they do not increase. 

2. INORGANIC SEDIMENTS. 

A greater portion of the organic and inorganic combinations which 
normal and pathological urine contains may be precipitated from it and 

25 



386 



SPECIAL DIAGNOSIS. 



appear as sediment. A distinction must generally be made whether 
such sediments appear in the still warm, recently passed urine, or 
whether the urine is clear when first passed and precipitates its con- 
stituents only when cool or after it has been standing for some time. 

According to the investigations of Moritz, all the crystals of the 
more important substances precipitated from the urine contain an 
albumin-like organic frame-substance. Organic nuclei are also demon- 
strable in those concretions which are not distinctly crystalline, but are 
globular and the like, and even in the minute granules of sedimentum 
lateritium. This is true whether the precipitates have formed in the 
urinary passages or outside of the body, either spontaneously or by 
chemical additions. 

Hitherto it has been supposed that only the coarser pathological 
concretions of urine contained such an organic nucleus, and from this it 
has been concluded that alterations of the mucosa in the urinary pas- 
sages which furnish abundantly such nuclear substance gave the first 
impulse to a formation of concretions. This line of argument is no 
longer vahd. 



{a) THE MORE FREQUENT INORGANIC SEDIMENTS. 

From acid urine there are deposited — uric acid, uric-acid salts, 
{sodiimi, lime), oxalate of lime. 

From the faintly acid, neutral (amphoteric), alkaHne urine there 
are deposited — ammonio-magnesium phosphates, phosphate of lime, car- 
bonate of lime, urate of ammonia, and sometimes uric acid. 

All these substances may occasionally be deposited from healthy 
urine.^ 

Uric Acid. — As is stated above, we find this as a deposit not only 
in acid, but sometimes in neutral and alkaline urine. It can often be 








<^<».a>B 





Fig. 146. — Uric acid and urates (Funke). 



Fig. 147. — Oxalate of lime (Laache). 



recognized with the naked eye in the form of yellowish-red, glittering 
granules, which are located upon the side of the urine-glass, or in the 
form of a yellowish-red powder at the bottom of the glass. Uric acid 

1 See p. 373. 



EXAMINATION OF THE URINARY APPARATUS. 387 

deposited from the urine always has this yellowish-red color, while the 
chemically pure uric acid is colorless. Under the microscope it shows 
the greatest variety of crystal forms and crystalline figures (see Fig. 
146). The basic form is the rhomboidal plate. But this is rare ; more 
frequently we have derivatives of this, the so-called " whetstone " (with 
a cross or in druses), ** barrel-shaped," also peculiar bundles of prisms ; 
lastly, amorphous lumps and clubs with separate, shining, smooth 
surfaces, — all easily recognized by their distinct color. We may arti- 
ficially produce a separation of uric-acid deposit by adding to the urine 
some concentrated solution of salt and allowing it to stand for twenty- 
four hours. Ordinarily, chemical reaction is not necessary. 

New-born babies during the first days of life often excrete a rather 
large amount of uric-acid crystals in the freshly-passed urine, and their 
kidneys also at autopsies usually show a so-called uric-acid infarction. 
This hitherto unexplained phenomenon is physiological. 

After the first days of life, however, uric-acid crystals in urine recently 
passed must always awaken a suspicion of uric-acid diathesis, while their 
presence in urine that has been standing for some time only admits the 
conclusion that it is not exactly wanting in uric acid, and nothing more. 

Amorphous, roundish, gravel-like concretions in the urine are al- 
ways pathological. 

Urate of Soda and I/ime. — When concentrated urine cools there 
is often a very abundant sediment, colored a flesh-red by the urinary 
pigment — " brick-dust sediment " or sedimcntum lateritiinn. When 
cooled to zero C. we can obtain it from any urine. It will be most 
easily recognized by the fact that it immediately completely dissolves 
when the urine is warmed (not boiled, because then there is a phos- 
phatic cloudiness and also coagulation of albumin,^ if present). Under 
the microscope the urates of soda and of hme are seen as very fine 
grains. They incline to settle upon the casts, and especially upon 
mucous threads. Uric-acid crystals form about half an hour after the 
addition of some muriatic acid. 

From concentrated urine the lateritious sediment is deposited at the 
ordinary temperature of the room, especially in engorgement of the 
kidneys, in attacks of diarrhea, in fever, and also in health.^ We should 
never conclude from its presence that there is increased separation of 
uric acid. We can only determine this by ascertaining the amount of 
uric acid and urate separated in twenty-four hours. 

A sedimeyitiim lateritiinn in fresh, still warm urine, as well as coarser 
sediments of urates (sand, gravel), always gives rise to the suspicion of 
nephrolithiasis. This is especially the case if blood is found in the 
urine, or even if only a few red blood-corpuscles are found by the 
microscope in the urinary sediment. 

In all cases of such concretions the chemical proof of uric acid must 
not be omitted. The concretion is powdered ; some of the powder is 
mixed with a drop of nitric acid upon a porcelain spoon and slowly evap- 
orated. A beautiful orange-red discoloration, which is turned into pur- 
ple-red by the addition of ammonia, proves the presence of uric acid 
\inurexid test). 

Oxalate of I^ime. — Single crystals of this may appear in any urine 

1 See p. 393. 2 See p. 363. 



388 



SPECIAL DIAGNOSIS. 



that has been standing for some time. The crystals are almost always 
tolerably small, sometimes minute regular octahedra, which are con- 
spicuous by their perfect form and strong refraction of light (envelope- 




FlG. 148. — Bulbous forms of urate of ammo- 
nia; triple phosphates (Laache). 



Fig. 149. — Phosphate of lime (Laache). 



form). They are rarely hour-glass- and dumb-bell-shaped. The crys- 
tals are insoluble in water, and are thus distinguished from chlorid of 
sodium. 




Fig. 150. — Ammonio-magnesium phosphates (after Meyer : Semiologie des Hams), 
b, tombstone crystals ; c, crossed and feather forms. 



These crystals occur in the urine in great abundance after eating 
certain fruits and vegetables, as apples, pears, cauliflower, and the dif- 
ferent kinds of sorrel ; and also in diabetes mellitus, catarrhal icterus, 



EXAMINATION OF THE URINARY AFPARATUS. 389 

hypochondria. Moreover, we cannot conclude, without further evidence 
than the mere occurrence of a somewhat large amount of these crystals, 
that there is increased separation of oxalic acid {oxalurid). The disease 
described by English physicians (and Cantani) as oxaluria does not 
seem to be a unity. This oxaluria occurs in cachexicE (tuberculosis, 
cancer). 

Ammonio-magnesium phosphate (triple phosphate) is found 
in urine that is simply alkaline and that is undergoing alkaline fermen- 
tation. Sometimes it forms the principal portion of the whitish sedi- 
ment. The basic form is the rhombic prism ; it is well formed in the 
*' coffin-lid crystals," often also of various other forms, and is then more 
difficult to recognize. The triple phosphates are all perfectly color- 
less and soluble in acetic acid, thus contrasting with oxalate of lime. 

Phosphate of lime as a basic salt occurs in amorphous grains in 
alkaline fermentation of the urine. 
It is soluble in acetic acid, but not 

by heat. As a neutral salt it occurs «■ ^ p 

in simple alkaline urine in the form ,. . 

of long wedges or knife-blades. \ •''^ri(J& ^ j/^ 

These disappear in alkaline fermen- ,-. ■ ^^ <.-.-i^'P v'J ••'^'4 • c^ o-'* . 

tation. (^:^ ifll^ "^* *'• 

Carbonate of lime in the form /-.^ Ci^ ^ ^'w^^^L ^V^ 
of spherules or crossed drumsticks ■' |^« ,- <;<& » '^^^'4^;'''/' J^x 

seldom occurs in alkaline urine. ^ '.'o / *«^ ®V ''^ j:.-;."., 

['* In highly alkaline urine, in which ^^ •.•:..•••.••'* ^' '^' 

the alkalescence is caused by car- 5Cl«^ ^%'' ''^■''' 
bonate of ammonia set free by de- p^ r, *■'•'%>■ •/•^O • 
composition of urea, carbonate of * ^ :{:': ^ ^h'- 

hme occurs in small quantity, but ■-'•" '.' %^ 

in an amorphous form. This is the '^ \. 

only form in which I have yet seen fig. 151. -Carbonate of lime (Laache). 
carbonate of lime in human urine." 

— Beale.] It is dissolved by the addition of muriatic acid, with effer- 
vescence. 

The so-called phosphaturia is a condition in which phosphates 
and carbonates are precipitated before or immediately after the urine is 
passed. But there is no increase in the phosphoric acid. The pre- 
cipitation is probably produced by the alkalinity of the urine. Phos- 
phaturia occurs in neurasthenia, hypochondria, chronic articular rheu- 
matism. 

Urate of ammonia accompanies triple phosphate in alkaline fer- 
mentation. The characteristic form is that of the thorn-apple (grayish- 
yellow or brownish opaque balls, from which fine needles project). 
When muriatic acid is added uric-acid crystals develop under the 
cover-glass. 

(3) MORE RARE INORGANIC SEDIMENTS. 

Hematoidin is exceptionally found in the forms of needles and 
plates mentioned before (see Fig. 46). Sometimes we see white blood- 
corpuscles which contain hematoidin needles, which project through 
the cell-membrane. 



390 



SPECIAL DIAGNOSIS. 



lyeucin and Tyrosin (see Fig. 152).— The characteristic forms of 
these substances, which almost always appear together, are sometimes 




Fig. 152. — Leucin (a) and tyrosin [b), cholesterin (^), xanthin (^) (Meyer). 

found in the sediment, more often only when we have evaporated the 
urine in a water-bath to the consistence of syrup or until we slowly 
boil down a drop of urine upon an object-glass until it is almost dry. 
Leucin appears in the form of faintly shining spheres, which some- 
times, if large, show radiating lines and concentric rings. Tyrosin 
crystalHzes in very fine needles, which commonly form druses and 
bundles. 

Leucin and tyrosin are products of the decomposition of albumin. 
They do not occur in normal urine. Diseases in which they are found 
and for which they may have diagnostic value are acute yellow atrophy 
of the liver and acute poisoning by phosphorus. They are also seen 
in variola and typhus abdominalis [typhoid fever], as well as in per- 
nicious anemia (Laache). 

Cystin sometimes occurs in the urine in health. Large quantities 
of cystin in the urine may cause the formation of cystin-calculi and 
excite cystitis, and are thus a pathological condition in themselves. 
According to recent investigations (Baumann, Brieger), there seems to 
be a connection between the occurrence of ptomains and cystin in the 
urine. Brieger assumes that by the presence of certain ptomains 
in the intestinal canal (and sometimes in mycotic enteritis) cystin 
forms a combination with the ptomains in the intestine, which over- 
flows into the urine. There the compound decomposes and cystin 
is again set free. Sometimes this does not take place, and so calculi 
are formed. The ptomains, in turn, may cause inflammation, espe- 
cially cystitis. Cystin, besides occurring in the urine in the form of 
calculi, is seen in the form of extremely thin, six-sided, and very per- 
fectly formed colorless plates. 



» 



EXAMINATION OF THE URINARY APPARATUS. 39 1 

{c) CONCRETIONS IN THE URINE. 

Urinary concretions originate in the pelvis of the kidney or in the 
bladder. According to their size they are called sand, gravel, or stone. 
Concretions formed in the renal basin when passing through the ureter 
cause more or less violent attacks of pam {renal colic) proportionate to 
their size. Sand and gravel usually pass without pain. The coarser 
concretions which remain in the kidney or bladder at times cause char- 
acteristic pain. 

Most frequently the concretions consist chiefly of uric acid and 
urates. They are then brown or brown-black, and tolerably smooth 
on the surface. Stones of oxalate of lime are densely hard and have a 
rough surface (mulberry calculi) ; they are dark brown. A combination 
of layers of uric acid and oxalate of Hme is likewise met with. Phos- 
phatic calculi are tolerably soft, but not infrequently they contain a 
kernel of the first-named substances (phosphate deposited upon the 
stone from the alkaline urine of cystitis [excited by the original stone]). 
Finally, we must mention stones of cystin and (extremely rare) xanthin. 
All these stones, with the exception of the phosphatic calculi, are formed 
in acid urine. 

A simple qualitative chemical examination of such a concretion, 
instituted for the purpose of recognizing the substances most frequently 
occurring, is made in the following manner : 

A sample of the substance is finely powdered, and then slowly raised 
to a red heat upon a porcelain spoon. If it does not burn at all or if 
only a very small portion of it burns, it consists mostly of inorganic 
combinations, most likely of oxalate of lime or of phosphates. 

Another sample is dissolved in dilute hydrochloric acid : if it con- 
tains carbonic acid, it effervesces. Then filter, and mix a part of the 
filtrate with ammonia till its reaction becomes alkaline, after which add 
acetic acid till the reaction becomes slightly acid : a white precipitate, 
insoluble by heat, is oxalate of lime. If there is no precipitate after 
the addition of the acetic acid, add some acetate of uranium : a yellowish 
precipitate of phosphate of uranium indicdlQS phosphoi'ic acid. 

If the substance is for the most part destroyed by red heat, a new 
sample is tested for uric acid by the murexid test.^ If the murexid test 
gives a negative result, dissolve a portion of the powder in undiluted 
nitric acid in the bottom of a test-tube, and evaporate a drop of the 
solution slowly on a porcelain spoon : a lemon-colored residue, which 
is not altered by ammonia, but takes on a reddish hue on the addition 
of a solution of caustic potash, proves the presence of xanthin. 

EXAMINATION OF THE URINARY CONSTITUENTS IN SOLUTION. 
I. ANOMALIES IN THE QUANTITY OF THE NORMAL CONSTITUENTS. 

In disease the normal constituents of the urine are variously in- 
creased or diminished. These quantitative variations, however, can 
only exceptionally be made use of for the diagnosis of disease. But 
they are important for determining the change of material and the re- 
moval of material that can be carried off by the urine in various diseases. 
This requires throughout an exact quantitative analysis, for the different 

1 See p. 1%-]. 



392 SPECIAL DIAGNOSIS. 

" approximative methods " have no value at all. We cannot here go 
into an explanation of the exact methods, but must refer to the hand- 
books upon urine-analysis. However, we mention briefly the most 
important anomaHes which belong here. We have already mentioned 
the quantities of the normal constituents of the urine (page 365). 

Urea. — This is increased in fever, either absolutely, as in pneu- 
monia, or relatively — that is, in relation to diminution in the amount 
of food taken. It is also increased in diabetes. We find it diminished 
in all forms of nephritis, but especially in uremia ; in cachexia of all 
kinds, especially if there is dropsy; and, lastly, sometimes in acute 
yellow atrophy of the liver. The very decided increase in the amount 
of excretion of urea which takes place immediately after the crisis in 
pneumonia is designated as post-epicritical. It is probably connected 
with the increase in the amount of water secreted by the kidney. 

Sehrwald^ devised a simplification of Knop-Hiifner's method of 
determining the amount of urea, which seems to us to be very prac- 
tical and relatively exact. We have not yet had an opportunity to 
thoroughly test the method. At least we recommend that it be tried. 

Uric acid is usually increased parallel with the urea in fever. Be- 
sides, it is increased in leukemia and pernicious anemia (with the first 
often very markedly), also in all diseases which affect the interchange 
of gases in the lungs ; and, lastly, with the uric-acid or gouty diathesis 
apart from attacks of gout, during which it is often diminished. 

The total amount of nitrogenous material in the urine, most im- 
portant for determining the metamorphosis of tissues, approximately 
agrees with the amount estimated from the urea, because uric-acid, 
creatinin, and xanthin bodies are insignificant in amount compared with 
the urea. Besides, the most practicable method for the quantitative 
determination of the urea (Liebig's) is really a determination of the 
total amount of nitrogen expressed as urea (C. Voit, Salkowski, and 
Leube). When determining both nitrogen and urea, of course it must 
be done apart from any possible albumin — that is to say, the latter 
must first be removed. 

Chlorid of sodium is pathologically increased during the resorp- 
tion of transudations and exudations, and also in intermittent fever, 
from the destruction of red blood-corpuscles (Kast). It is diminished 
in fever, nephritis, and in many cachectic conditions. [In pneumonia, 
during the stage of exudation and until resolution begins, the chlorids 
are diminished or disappear from the urine. While the disappearance 
of the chlorids from the urine is not characteristic of this disease alone, 
it shows that exudation is still going on or that resolution has not yet 
commenced.] 

Sulphuric acid interests us chiefly with reference to the associated 
ethylsulphuric acid (phenol-, indoxyl-sulphuric acids). It is found 
with increased separation of indican and carbolic acid. Regarding the 
former, see page 369. The latter occurs with the internal and external 
use of carbolic acid. 

It has been found that the phosphates are diminished in rachitis, 
also in acute yellow atrophy of the liver. In nephritis they are not 
infrequently diminished. 

^ Munchen. med. Wochenschrift^ 1888, No. 46. 



EXAMINATION OF THE URINARY APPARATUS. 393 

2. ABNORMAL CONSTITUENTS. 

Albumin. — It has already been mentioned that the urine of healthy 
persons not infrequently gives certain albumin reactions, but that, 
according to more recent investigations, these albuminous substances 
are not the same as occur in renal albuminuria. Moreover, this 
albumin reaction of normal urine is usually produced by those sub- 
stances which form the so-called nubecula : mucin-like substances, prin- 
cipally mucin and nucleo-albumin. These substances originate in the 
urinary passages, and may be increased in all affections of the urinary 
tract, especially in catarrh, but also in nephritis. 

It is difficult to separate these substances chemically, and therefore 
they have recently been classed together under the name of " mucin- 
like substance of the urine." Their presence may give rise to the as- 
sumption of a renal albuminuria. 

Since the mucin-like substance is partly precipitated as the urine 
cools, forming the nubecula, it is recommended in testing for albumin 
always to use cold urine which already shows the nubecula, and to be 
careful not to get any part of the nubecula into the test-tube. I have 
frequently found, in testing freshly evacuated urine during office hours, 
that it gave a distinct reaction of albumin, while the same urine after 
standing for some time proved to be free from albumin. 

Nevertheless, also in cold urine that part of the mucin-like substance 
which remains dissolved may give a part of the albumin reactions. To 
avoid this source of error we add an excess of acetic acid to a sample 
of urine, and, if it is concentrated, dilute it with a little water. Cloudi- 
ness indicates mucin-like substance. It is best to clarify the sample by 
repeated filtration, and then to examine it for pathological albuminous 
substances. 

For practical purposes we recommend the following method for all 
cases : 

Mode of Procedure. — If we expect to find a very small quantity of 
albumin in a given specimen of urine, it is to be examined only after it 
has cooled. When the reaction of albumin is distinct this precaution is 
unnecessary. If we find in the cold urine a very slight reaction, this 
may still be due to the mucin-like substance. To exclude this we make 
the above-mentioned reaction with acetic acid. If it is positive, we try 
to remove the mucin-like substance by repeated filtering or make the 
heat and nitric-acid test, which precipitates only serum-albumin and 
serum-globulin, and while cooling precipitates the albumoses, and, at 
any rate, only a trace of mucin-like substance. 

[The mucins, as stated above, interfere with the tests for serum- 
albumin. Of the various methods for getting rid of the mucin-like sub- 
stance, the following one can be relied upon for getting rid entirely of 
mucin from mucous membrane, partly of that from bile and also of 
serum-globulin if that be present : To i ounce of urine add \ ounce of 
distilled water; add 30 drops of a 25 per cent, solution of magnesium 
sulphate, then 30 drops of a 25 per cent, solution of sodium hydrate. 
Shake thoroughly and allow it to stand for ten minutes ; then filter 
through a wet four-ply filter. Dilute the filtrate with one-fourth its 
volume of glacial acetic acid or one-half its volume of acetic acid ; 



394 SPECIAL DIAGNOSIS. 

boil ; set aside for an hour ; then filter through powdered talc and 
a wet four-ply filter-paper.] 

The albuminous substances, which in the conditions reckoned as 
albuminuria in the narrow sense can be separated, are serum- albumin 
and senim-globulin. Their amount varies from a trace to \ per cent., 
very exceptionally more. Generally, it remains below \ per cent. The 
secretion of hemialbumose is very rare, and thus far has not been 
found to have special diagnostic significance. Of late we are not 
accustomed to regard pcptontiria as albuminuria. It will be considered 
at the close of this chapter. 

A renal or '' gemiine'' albiimimiria occurs : in all forms of acute and 
clironic neplmtis, in amyloid kidney^ in engorgement of the kidneys ; in 
hydremic conditions of the blood, as anemia, leukemia ; in fever, and in 
acute poisoning : in these two last-named cases, especially in the latter, 
there occur, besides, all the transitions to nephritis : lastly, after epileptic 
attacks, and with apoplexy {transitory albuminuria). 

It is no longer doubtful that in all these cases we have to do ex- 
clusively, or at least chiefly, with an injury to the epithelium of the 
loops of the glomeruli or Malpighian corpuscles. Healthy epithehum 
holds back serum albumin ; when the epithehum is diseased, filtration 
of albumin is no longer restrained. 

Besides, there has recently been discovered a peculiar form of albu- 
minuria which is distinguished from other forms by the absence of all 
pathological signs in the urine, especially of cylinders — cyclic albu- 
minuria} 

Further, albumin may appear in solution in the urine, originating in 
the urinary passages when blood and pus, as in cystitis, are mingled 
with the urine in the bladder. The amount of albumin, however, is 
then always small. 

Qualitative Tests for Albumin. — We select a few, from the great 
number of tests for albumin, which have the tolerably uniform ap- 
proval of authors,^ and which, according to our experience, have the 
preference. 

The preliminary condition is that the urine be not contaminated, as 
by menses, leucorrhea or spermatic fluid, and that it be clear. The 
latter is the more necessary in proportion as the amount of albumin 
is small. In order to be able to discover it when only a very little is 
present it is necessary to filter the urine until it is perfectly clear. 

{a) Addition of Acetic Acid and Potassium Ferrocyanid. — By acetic 
acid the urine is rendered distinctly acid, and then the cold urine is 
mixed with a few drops of a watery solution of potassium ferrocyanid. 
There occurs a very fine flocculent precipitation of albuminous sub- 
stances, serum-albumin, globulin, and also of the albumoses, but not 
of the peptones. A milky cloudiness is produced by the precipitate if 
the quantity of albumin be moderate. If the percentage of albumin 
be very small, the turbidness appears somewhat later, after about a 
minute. If any develops later still, it has no significance. The test 
is very safe and very sharp, but has the one drawback that it indicates 
also the mucin-like substance. Therefore it is recommended to note 

^ Regarding this, see p. 396. 

'^ See, regarding them, Penzoldt's Aeltere und neuej-e Hornproben. 



EXAMINATION OF THE URINARY APPARATUS. 395 

whether cloudiness appears after the addition of acetic acid. If there 
be acetic-acid cloudiness, it is made only a little more pronounced by 
the addition of potassium ferrocyanid, and shows that the mucin- 
like substance is present with absence of renal albumin. Then make 
other albumin-tests, especially that by boiling and addition of nitric 
acid, or precipitate in a new test the mucin-like substance with an 
excess of acetic acid, clarify by repeated filtration, and then examine 
the filtrate for albumin. In this case it is well to try to filter off the 
precipitate produced by the acetic acid. 

The potassium ferrocyanid test will be rendered more sharp if it 
is compared with another test-tube which contains urine to which only 
acetic acid has been added. The reaction is made still more distinct 
by following the suggestion made by v. Jaksch, which is to super- 
impose the urine with a mixture of moderately concentrated acetic 
acid and a few drops of solution of potassium ferrocyanid. With a 
minimal quantity of albumin there is seen a whitish ring at the line of 
contact of the hquids. 

(b) Boiling and the Addition of Nitric Acid. — If the urine has a neu- 
tral or alkaline reaction, acetic acid, diluted one to ten, must be added 
to render it acid before boiling. If there is cloudiness, it can only 
be due to one of two causes : albumin or phosphates. To determine 
which of these it is, we add about ten drops of nitric acid, when the 
phosphatic deposit is immediately dissolved ; but if the deposit is 
albumin, this is made more distinct. When the albumin is somewhat 
abundant, the deposit can be immediately recognized by its floccular 
appearance. This test may also be made by mixing the urine with 
about one-fifth part of nitric acid and then boiling. The test is a sharp 
one, showing even 0.005 to o.Oi per cent, of albumin, and, being tol- 
erably certain, in general is to be recommended. A second modi- 
fication is perhaps somewhat more distinct than the first : there are 
precipitated immediately serum-albumin and globulin, soon after cool- 
ing the albumoses, and besides, probably, also a part of the mucin-like 
substance. A precipitation that takes place later than a quarter of an 
hour after cooling cannot with certainty be regarded as due to albu- 
minous substances. 

(c) Picric-acid Test. — We add to the urine a few drops of a con- 
centrated watery solution of picric acid : if it immediately becomes 
cloudy, it shows albumin, but cloudiness appearing later shows nothing 
(Johnson, Penzoldt). There is precipitation of albuminous substances, 
including albuminous and mucin-Hke substances, and also resinous acids. 
Otherwise it is a certain and sharp test, not less to be recommended 
than the others. 

Portable Tests for Albumin. — These are such reagents as the phy- 
sician may easily carry with him and use at the houses of his patients. 
They are not to be strongly recommended, as they all have some 
shortcomings. There are two which give safe results if there be well- 
developed albuminuria : 

(d) Geisler's Albumin Test-papers.^ — These consist of a piece of 
filter-paper saturated with a concentrated solution of citric acid, and 
of another saturated with a 3 per cent, solution of potassium iodid, 

[^ They may be obtained of several manufacturing chemists.] 



396 SPECIAL DIAGNOSIS. 

added to a 12 or 15 per cent, solution of corrosive sublimate. We 
first put one of the strips of the first into the urine — if very alkaline, 
more than one — then one of the second papers, and shake it. Cloudi- 
ness due to albumin appears pretty promptly. Peptone is also pre- 
cipitated, which in many cases can cause deception.^ In concentrated 
urine urates are also precipitated, but these can afterward be dissolved 
by heat. Deception from the solution of particles of paper making a 
cloudiness is not possible if it is carefully examined. As a preliminary 
test at the sick-bed this method is to be recommended. But we ought 
not to be satisfied with its result, and should always afterward employ 
one of the tests previously mentioned. 

(e) Furbringer's Reaction. — This consists of gelatin capsules con- 
taining mercuric chlorid, sodium chlorid, and citric acid. The reac- 
tion has about the same shortcomings as the former, only it is a little 
cleaner because minute fibers of paper are excluded. 

If we examine the urine a number of times in twenty-four hours, 
and find that there is a periodic presence and absence of albumin, we 
designate this condition as cyclic albiiminiiria} It never occurs after 
rest at night ; the albumin is generally separated after exertion. In 
case this condition is suspected we are to examine the urine several 
times during the day, and especially toward evening, as well as directly 
after rising in the morning. Klemperer has made a very clear demon- 
stration of the course of the separation of the albumin. He places 
about 5 c.cm. of the urine, passed at different times during the day, in 
a series of reagent-glasses, and then boils them with the addition of 
nitric acid. The height of the deposit in the glasses as they are ar- 
ranged in a row, may be regarded as a direct delineation of the 
"albumin curve." 

Behind these cases of cyclic albuminuria there are hidden, on the 
one hand, cases of disappearing acute nephritis, and, on the other, 
beginning chronic nephritis. Some of them, especially those which 
occur in children, must be regarded as benign '' fimctiojiaV {^^ diseases. 
The differential diagnosis between functional albuminuria and nephritis 
is chiefly founded upon the question whether other nephritic alterations 
of the urine are present, particularly organic constituents, and what 
the condition of the heart is. Moreover, cycHc albuminuria not infre- 
quently occurs in diseases of the heart, preponderately in infancy. 

Some of the benign cyclic albuminurias, particularly those that 
occur after exertion, are nucleo-albumins. 

Quantitative Test for Albumin. — Here, as in all quantitative de- 
terminations, the urine of exactly twenty-four hours must be mixed, 
and a portion from this mixture examined. The urine for exactly 
twenty-four hours can be obtained if we have the patient urinate early, 
say shortly before seven o'clock, and then keep all the urine that is 
passed after that hour till the next morning at exactly the same hour, 
passing his urine again at seven o'clock. * 

It is possible to make an exact quantitative determination only by 

^ See Peptonuria, p. 398. 

2 [In the British Medical Journal, Jan. 31, 1891, p. 218, Dr. Herrini^ham gives a 
valuable and careful study of a case of cyclical albuminuria vi^hich was under his caie at the 
West London Hospital. — Translator. '\ 



EXAMINA TION OF THE URINAR V APPARA TUS. 



397 




completely separating the albumin from a measured quantity of urine. 
Filter, wash the residue upon the filter-paper, dry, and weigh it. (For 
particulars regarding these processes, see text-books upon Urine- 
Analysis.) This examination can only be conducted in a laboratory. 
There is no mode of procedure which is more simple, nor one that is 
so nearly exact as this. The polarizing method is only appHcable 
when there is a considerable amount of albumin. 

A substitute for the exact quantitative determination is quite com- 
monly found by endeavoring to estimate the amount of deposit which 
results from the qualitative determination, especially 
by the boiling nitric-acid test ; we wait a long time — 
till it has settled in the reagent-glass — and then we 
speak of one-half, one-quarter, or of the "whole " being 
albumin by comparing the volume of albumin that 
can be seen with the whole amount of urine in the 
reagent-glass. It may be assumed that one-half the 
volume of albumin, if the reagent-glass has stood for 
one hour, corresponds to about 0.2 to 0.6. This 
estimate is extremely unreliable, being chiefly de- 
pendent upon the size and thickness of the flakes of 
albumin. But if we always employ the same test for 
albumin, it is certainly not valueless for judging of 
the variations in the separation of albumin in the 
course of the disease. 

More exact is the method with Esbach's albumin- 
ometer, although it acts upon the same principle — 
that is, on the determination of the albumin from the 
volume of the precipitate — and so is only approxi- 
mative. Its greater exactness only rests upon the 
fact that to a given quantity of urine there is always 
added the same amount of a reagent adapted for 
uniform sedimentation and mixed in the prescribed 
way, that a definite period of time is allowed for 
sedimentation, and that the height of the sediment is measured. 

This albuminometer — a graduated thick reagent-glass — is filled with 
urine to the mark U ; from there to R, with the reagent. This reagent 
consists of 10 grams of picric acid and 20 grams of citric acid to 
1000 of distilled water.^ The glass is then closed with a rubber cork, 
turned upside down ten times, and allowed to stand undisturbed for 
twenty-four hours, best in a special stand. After this period of time we 
notice at what mark of the scale on the glass the albuminous deposit 
stands. The marks each give -^ per cent, of albumin. As the scale 
only goes as far as 0.7 per cent., urine that is strongly albuminous must 
be diluted in a definite way before the test. We must avoid producing 
air-bubbles, because these cause the precipitate or a part of it to swim, 
and for this reason we are not to shake the glass. If there are air- 
bubbles, they must be removed with a pipette. 

In most cases the method is sufficiently exact for clinical purposes. 

1 The exact amounts of both acids (chemically pure and dry) are to be dissolved in looo 
grams of water, made hot, and, after cooling, any deficit in the amount of fluid is to be made 
up by the addition of water to 1000 grams. 



Fig. 1 = 3 — r bach's 
albuminometer. 



398 SPECIAL DIAGNOSIS. 

[The apparatus is not at all expensive, and can be obtained from deal- 
ers in chemical apparatus.] 

A series of experiments, recently published by apothecary Dr. Ross- 
ler (Baden-Baden), gives the following differences : 

Albumin determined by Albumin determined by 

weighing. Esbach's method. 

1. 0.01535 per cent • o.oio per cent. 

2. 0.0286 " 0.04 " 

3- 0-0515 " 0.03 

4. 0.1271 " 0.07 " 

5. 0.217 " 0.22 " 

6. 0.328 " 0.28 " 

7. 0.404 " 0.23 " 

8. 0.483 " 0.36 

9. 0.486 " 0.59 " 

10. 0.66 " 0.33 " 

From this table it is seen that the inexactness of Esbach's method is 
regularly too much upon one side, and then too little upon the other. 
Without visible cause, in some cases the precipitate is so small that 
after a few hours one is tempted to abandon the test. 

Notwithstanding these defects, the small, very cheap apparatus is to 
be strongly recommended, because it is a great advance upon the simple 
estimate in the ordinary test-tube, and because we have no more exact 
method which anywhere nearly approaches this in simpHcity. 

Rare Forms of Albumin. — Peptone (v. Jaksch, Maixner, and 
others). — This never occurs in healthy urine. Pathologically, it occurs 
sometimes in ordinary albuminuria, and again independently — peptonu- 
ria. It occurs in a great number of very different conditions — in large 
abscesses, in emphysema, sometimes in pneumonia ; likewise in acute 
rheumatism, scorbutus, phosphorus-poisoning ; also, in carcinoma ven- 
tricuH, in puerperal fever, in typhus abdominalis [typhoid fever], etc. 
Hence this very remarkable substance has no value for diagnosis. Its 
determination, even qualitative (biuret reaction), is, for various reasons, 
difficult. 

Albumoses do not occur in the urine very frequently ['' albuniostiria "). 
We shall refer to these urinary constituents very briefly, only remarking 
that we may suspect their presence if the urine becomes turbid as it 
cools after the use of the heat and nitric-acid test. Hitherto this sub- 
stance has had no diagnostic significance. 

Kahler has recently observed hemialbumose in multiple primary 
lympho-sarcoma of the spinal cord. 

Fibrin occurs in the urine in hcniatziria, in deep-seated inflammation 
of the urinary passages, in tuberculosis, in poisoning with cantharides, 
and in chyluria. It is recognized by the fact that it coagulates sponta- 
neously in the urine, although sometimes only after the urine has stood 
for some time. The coagula are then to be further examined. 

In this place are to be mentioned two phenomena that occur in those 
diseases of the kidney that stand in close relation to albuminuria — 
dropsy and uremia. 

The dropsy of kidney-disease manifests itself, v^ery frequently, first in 
the skin of the face, especially at the eyelids. With contracted kidney 



EXAMINATION OF THE URINARY APPARATUS. 399 

the edema is very fugitive, often changing its place ; in a large number 
of cases it is entirely wanting during the entire course of the disease. 
With large white kidney it is more decided and stable ; there is often a 
very soft, doughy edema. In this respect acute nephritis varies very 
much. In all forms of Bright's disease, from its association with heart- 
weakness, a new factor may come into play for the development or in- 
crease of the edema and effusion into the cavities of the body (dropsy 
of engorgement). 

With reference to the cause of the dropsy in kidney-disease, no doubt 
the most important element is the diminished elimination of water by 
the kidneys. This retention of water often, especially if excessive, has 
the effect that even a slight, perhaps a scarcely noticeable, dropsy of 
the skin and subcutaneous tissue considerably disturbs the excretion 
of water by perspiration. At any rate, it is certain that the dropsy of 
kidney-disease is, in many cases, not explained by the retention of 
water ; but neither is Cohnheim's hypothesis, that the walls of the ves- 
sels are abnormally previous, at all generally accepted. This whole 
matter is still an open question. 

Uremia is an association of nervous manifestations which, at least in 
the majority of cases, is dependent upon the retention in the blood of 
urinary products (especially uric acid). In individual cases of " uremic " 
manifestations, however, this explanation is not correct, and the nature 
of such cases is not yet clear (edema of the brain, Traube (?)) ; sometimes 
anatomical changes in the brain, Strumpell (?), etc. We coincide with 
Striimpell's view, that uremia is a multifarious manifestation — a number 
of conditions which, by their presence and their phenomena seem to 
belong together, are in reality different. 

Slight uremic symptoms may last, with slight changes, for weeks, 
even months, as somnolence, restlessness, headache, malaise, vomiting, 
dyspnea (uremic asthma), indications of Cheyne-Stokes' respiration, 
slight transitory disturbances of vision. The more severe symptoms 
are — decided cloudiness of intelligence, even to coma or delirium ; 
maniacal conditions ; convulsions, varying from single convulsive 
movements to pronounced epileptic attacks ; and temporary amaurosis. 
There may be slowness of the pulse, with acceleration later, and fever. 
In individual cases there occur evident symptoms of cerebral conges- 
tion — convulsions, paresthesiae, paralysis of an arm or of one side of 
the body, and aphasic manifestations. 

Mucin and Nucleo-albumin. — These bodies have already been men- 
tioned a number of times. They are products of the cells of the 
mucosa of the urinary tract, are present in all specimens of urine, and 
are precipitated in part as nubecula. They are increased in all forms 
of catarrh of the urinary tract, and also in nephritis. Their proof has 
been given on page 393. 

Coloring Matter of the Blood. — The occurrence of this body has 
also been previously mentioned.^ Here we have to refer to the tests 
for hemoglobin or hematin in solution. 

First, it must be mentioned that of course the urine shows the pres- 
ence of albumin in both hematuria and hemoglobinuria. The amount 
of albumin is always small, provided there is no albuminuria besides. 

1 See p. 370. 



400 SPECIAL DIAGNOSIS. 

Blood-pigment will be shown to be present by the following pro- 
cedures : 

(ci) Heller's Test. — A portion of urine is made decidedly alkaline 
with caustic potash and boiled in a reagent-glass : the phosphates are 
precipitated as very dehcate floccules, which look like mucus and 
slowly sink to the bottom. They accompany the blood-pigment, and 
hence look brown or red-yellow. When the urine is concentrated we 
dilute it, after boiling, by filling the reagent-glass with water, because 
the color of the floccules is easily concealed. Urine that is poor in 
phosphates, as in nephritis, gives no phosphatic deposit. Such urine 
must be mixed before making the test with some that has the normal 
amount of phosphates. The color described as belonging to the 
phosphatic deposit occurs nowhere else, except with urine containing 
chrysophanic acid, but this latter is recognized by its change in color 
after the reaction. This test is very simple, certain, and with clear 
urine is tolerably distinct. 

(b) Test with Tincture of Guaiac. — The reagent consists of tinct. 
guaiac, ol. terebinth, ozonisat., da. lo parts. A small portion of this, 
placed in a reagent-glass, is carefully covered with urine: when the 
coloring matter of the blood is present there is, besides the dirty, white 
deposit of resin, an indigo-blue ring. When shaken up the whole 
contents of the glass become a non-transparent, bright blue. The test 
is a very distinct one. 

{c) Test for Hemiii. — This is made with a large drop of urine or 
urinary sediment, exactly in the same way as has been described 
already ^ for finding it in the material vomited. The test is more dis- 
tinct than the preceding, particularly if we boil it down in a porcelain 
dish and then apply the reaction. 

(d^ Spectroscopic Examination. — This gives the absorption-bands of 
methemoglobin — namely, in yellow, green, and red. Of course this is 
an extremely distinct test. 

Indican. — (See page 369.) 

BILE-PIGMENTS AND BILE-ACIDS. 

Gmelin's Test for Bile-pigments. — We pour a small quantity 
of nitric acid into a reagent-glass, and add to it one or two drops of 
fuming nitric acid, forming a trace of an admixture of nitrous acid. 
To this mixture we very cautiously add a layer of urine, by permitting 
it to flow from a pipette down the side of the glass held obliquely. 
When the bile-pigment is abundant, if the fluids are kept carefully 
distinct there is a ring of green (blue), violet, and red. The first 
named constitutes the test. There is no reaction when there is only 
a small amount of bile-pigment. 

Rosenbach's modification is decidedly more distinct. Filter 
some urine, not too little (about 200 c.cm.), through a medium-sized 
filter, unfold it, and place it upon a white surface, and then pour upon 
it a few drops of the mixture of nitric and nitrous acids. The colored 
rings form upon the filtrate. 

Gmelin's test is still sharper if, after acidulating the urine with 

1 See p. 330. 



EXAMINATION OF THE URINARY APPARATUS. 401 

acetic acid, we shake it up with chloroform, pour off the urine, and 
then with the chloroform, colored yellow by the bile-pigment, make a 
layer with the nitric-acid mixture. 

Penzoldt recommends a filtrate prepared as in the Gmelin-Rosen- 
bach test (allowing a good deal of urine to flow through), over which 
acetic acid is poured, and this is allowed to flow into a broad glass 
vessel, so as to have it in a shallow, but broad, layer. The acetic 
acid becomes yellow-green, gradually becomes green (quicker, if it is 
warmed), even bluish-green. Penzoldt declares that this test is very 
distinct. 

Rosin's Test. — H. Rosin has recently recommended a test with 
tincture of iodin (tinct. iodin, i part, absolute alcohol, 9 parts). The 
reagent is carefully superimposed on the urine to be examined. If 
bile-pigment is present at the junction of the liquids, there is a green 
ring. The test is very beautiful, but we have not yet tested its sharp- 
ness and certainty. 

Pettenkofer^s Test for Bile-acids (glycocholic, taurocholic, and 
cholal acids). — This test is based upon the fact that the addition of a 
weak solution of cane-sugar (i : 500) and a trace of concentrated sul- 
phuric acid to urine causes a violet-red color. We must be careful not 
to have the resulting elevation of temperature too high — at most not 
higher than about 50° C. 

For various reasons this last reaction is uncertain. Its result is 
reliable only when the bile-acids, if present, have been isolated. At 
any rate, the bile-acids have only a slight diagnostic value : a trace 
sometimes occurs in normal urine, while we find in undoubted cases 
of jaundice due to engorgement of bile often none, or only a trace, 
because frequently in the transmission it becomes broken up in the 
blood. Hence in cases of icterus we cannot account for the absence of 
the bile-acids from the urine by the assumption that it is not an hepa- 
togenous icterus. On the other hand, an abundance of bile-acids in the 
urine proves that the jaundice is due to engorgement of bile. More- 
over, it is clear that if we wish to logically explain " hepatogenous " 
icterus by the idea of engorgement of bile in the liver, we must assume 
an increase of the bile-acids in this jaundice also. As a matter of fact, 
this is found to be the case in toxic " hemato-hepatogenous " icterus 
(arseniuretted hydrogen, toluylendiamin — Stadelmann). 

Grape-sugar. — Pathologically, grape-sugar occurs in the urine — 

1. In diabetes inellitiis, usually in considerable quantity — as much as 
2 to 5 per cent, (minimum J, maximum about 10 per cent.). The urine 
is increased in amount, is bright and clear, of higher specific gravity, as 
has already been mentioned. 

We will not here enter upon the differential diagnosis of the different 
forms of diabetes.^ 

2. As pathological glycostiria (Frerichs), usually in small quantity 
and almost always temporarily : after poisoning with carbonic oxid, 
curare, amyl nitrite, turpentine; sometimes with mercury, morphia, 
chloral, prussic acid, sulphuric acid, alcohol ; again, in acute infectious 

1 See special papers, particularly those of Naunyn : " Die diatet. Behandlung des Dia- 
betes melhtus," Volkmann's Sammlung klin. Vortrdge, Nos. 349 and 350; also various 
handbooks. 

26 



402 SPECIAL DIAGNOSIS. 

diseases (typhoid, scarlet fever, diphtheria, etc.) ; in diseases of the oblon- 
gata (but here it is more lasting) ; and froi?i other neurotic causes, as 
excessive mental exertion, neuralgia, injuries to the central nervous 
system, concussion of the brain, etc. ; also, after epileptic convidsiofis 
and apoplexia cerebri ; as alimentary glycosuria, after partaking of a 
considerable quantity of sugar,' or even after eating carbohydrates. 
The latter must always awaken a strong suspicion of commencing 
diabetes. 

The bouhdaiy-line between physiological and pathological alimentary 
glycosuria is difficult to draw. The latter form depends upon a morbid 
disturbance, and more particularly represents the precursor of diabetes. 
According to Moritz, lOO grams of sugar will not produce any glyco- 
suria in a healthy person, and he accords with the advice of v. Noorden 
to give lOO grams of grape-sugar on an empty stomach in the morning 
as a test for pathological glycosuria. If sugar appears in the urine, v. 
Noorden thinks commencing diabetes should be suspected. Such a 
test may be made now and again in members of diabetic families and 
in fat people. 

It is to be remarked that the urine is always to be examined for 
sugar when it has a decidedly high specific gravity ; but particularly 
if it is clear and abundant and, at the same time, has a high specific 
gravity. 

After a single examination it is often difficult to make a distinction 
whether the case is one of diabetes or glycosuria. Only careful further 
observation of the patient can settle the question. Glycosuria is tem- 
porary and ceases definitely. Every return must direct the attention 
to a diagnosis of diabetes if one of the causes of glycosuria mentioned 
does not again come into play. 

Qualitative Tests for Sugar. — Bismuth Test (with Nylander's. 
modification). — For this purpose we employ Nylander's reagent : 2 
parts basic bismuth nitrate and 4 parts sodium tartrate to 100 parts of 
8 per cent, solution of sodium hydrate. Of this we take I part to 10 of 
urine and boil them together. After a few minutes, if there is only a 
little sugar — sometimes only after it has cooled — it becomes black from 
the reduction of the contents of the reagent-glass with the formation 
of the bismuth oxid if the urine contains as much as i per cent, of 
sugar. 

It is evident that this is a very distinct test. It is only not appli- 
cable when there is albumin in the urine or ammoniacal fermentation 
has taken place. (Remove the albumin and apply Trommer's test.) 
Where there is only a slight reaction, it has no great certainty. Only 
a negative result shows that there is certainly no sugar (Kistermann). 

Trommer's Test. — To a given quantity of urine we add about one- 
third as much liq. potassse, and to this, drop by drop, of a 10 per 
cent, solution of copper sulphate, as long as it is held in solution by 
mixing. It is important to add, as exactly as possible, just so much 
of the copper sulphate as is dissolved by shaking ; and hence the 
addition of the copper must be interrupted as soon as the first trace of 
a flocky precipitate remains after shaking the test-tube. Then it is 
heated, but not allowed to boil. An abundant precipitate of yellowish- 

1 See p. 366. 



EXAMINATION OF THE URINARY APPARATUS. 403 

red hydrated cupric suboxid, which appears even before the fluid 
reaches the boiUng-point, shows the presence of sugar. The yellow 
color of the liquid or a precipitate that takes place later may be caused 
by a very small amount of sugar, but also by uric acid and creatinin. 

Albumin and salts of ammonia prevent the reaction, and therefore 
albumin must first be removed by boiling after acidulation with acetic 
acid. Urine which has undergone alkaline fermentation, however, 
cannot be used. Urine containing a large percentage of creatinin and 
uric acid sometimes prevents a positive result of the test if the per- 
centage of sugar is small, as these substances are capable of holding 
in solution only a small amount of oxydulated ^ copper. It is neces- 
sary to make the fermentation test^ with the urine of these cases. 

When the percentage of sugar is considerable (over 0.5 per cent), 
Trommer's test is very useful; below 0.5 per cent, it is not safe or 
distinct. If it gives a very small precipitate, or one that appears some- 
what late, or if it results in a yellow coloration without precipitation, 
Nylander's test at least must be applied, but it is better still to use the 
fermentation test. 

Phenyl-hydracin Test (v. Jaksch). — About 2 grains of muriate of 
phenyl-hydracin and 3 of sodium acetate are put into a reagent-glass 
which is filled half-full of water. After heating the glass is to be filled 
with the urine to be tested. It is allowed to stand for fifteen or twenty 
minutes in boiling water ; then it is put into a beaker-glass filled with 
cold water. When there is a large amount of sugar there is formed a 
macroscopically visible deposit. With a small amount of sugar, after 
standing, there is a deposit, which can be seen with the microscope, 
of yellow needles, single and in druses — phenyl-glucosazon. Yellow 
plates and brown balls prove nothing. Albumin that may be present 
must previously be removed by boiling the urine. Von Jaksch urges 
this test because it is a very exact one. Its difficulty consists in this, 
that the needles of phenyl-glucosazon are sometimes not alike clearly 
characteristic in distinction from the yellow plates, etc. ; which proves 
nothing, these latter not being crystallizable in alcohol. Nevertheless, 
the test seems to be a very sharp one, but its certainty is doubted by 
some. 

Of the other very numerous tests for sugar we only mention the 
following : 

Moore's liq. potassse and boiling test, which causes urine that con- 
tains sugar to become brown — not a very certain and sharp test ; and 
the test with diazo-benzol-sidphiiric acid and potash recommended by 
Penzoldt. 

One test, of great importance and highly recommended on account 
of its absolute certainty, is somewhat troublesome : 

Fermentation Test. — This rests upon the peculiarity that yeast has 
of separating sugar into alcohol and carbonic acid (succinic acid, etc.). 
This test should always be applied when the reduction tests yield 
slight or doubtful results, and particularly when there exists a doubt 
whether the reduction is caused by sugar or so-called reducing sub- 
stances.^ It is especially necessary to take into consideration that 
these reducing substances which are not sugar (creatinin, uric acid, 

[1 Copper oxydule = CujO.] ^ See below. ^ See p. 366. 



404 SPECIAL DIAGNOSIS. 

and others) may be present in increased quantity in fever and when 
the urine is concentrated. (According to Moritz, maximum reduction 
= 0.5 per cent, of grape-sugar.) After chloroform narcosis Kast has 
found, besides, a reducing substance in the urine whicli is probably a 
paired glycuronic acid. 

The fermentation test may be made in a simple way, as follows : 
Three perfectly clean reagent-glasses are filled about two-thirds full of 
mercury. The first is then to be filled with some of the urine to be 
tested and a little yeast ; the second is to be filled with normal urine 
and some yeast; the third with a thin, watery solution of sugar and 
yeast. It is well to add to each a drop of a solution of tartaric acid. 
All three tubes are now placed upside down in a tray of mercury by 
covering the openings with the thumb as we invert them. The second 
tube should not show any development of carbonic acid, but if it should 
do so the yeast was not perfectly free from sugar, and the experiment 
must be repeated with yeast that is perfectly pure. The third glass 
should show the development of carbonic acid, otherwise the yeast has 
become inactive. If the second and third test-tubes fulfil the condi- 
tions named, we may draw a safe conclusion from the behavior of the 
first tube : if it shows formation of carbonic acid, the urine contains 
sugar, but if it does not show development of COg, no sugar is present. 
The development of carbonic acid is recognized by the existence of 
gas in the upper part of the inverted tube. Its presence is made cer- 
tain by its being absorbed when potash lye is introduced into the 
tube. 

Fermentation-tubes are very helpful in employing the fermentation 
test (see Salkowski-Leube, Penzoldt). [Dr. Max Einhorn's fermenta- 
tion saccharometer is one of the simplest yet devised. It is graduated 
so as to show the percentage of sugar.] 

Quantitative Determination of Sugar. — This is indispensable if 
a case of diabetes is to be carefully observed, particularly for determin- 
ing its severity, its course, and especially the effect of treatment. From 
the qualitative examination we cannot draw satisfactory conclusions as 
to the amount of sugar except by a comparison of the specific gravity 
of the urine with its quantity. 

We make use of the mixed urine that is passed in exactly twenty- 
four hours,^ 

We only adduce two of the most important and most used methods 
— namely, that of estimating it with copper sulphate and by circum- 
polarization. The method recently recommended of determining the 
sugar by measuring the specific gravity before and after fermentation is 
very circumstantial, and requires more exact araometers than those 
commonly used. The determination from the volume of carbonic acid 
resulting from fermentation (gaso-volumetric fermentation test) can 
only be carried out in the laboratory. 

1. Estimating Amount of Sugar by Fehling's Solution (after 
Salkowski-Leube). — This method ascertains the percentage of the re- 
ducing substance in the urine ; therefore, besides the percentage of 
grape-sugar, it measures also that of levulose — an inexactness, how- 
ever, which is not of much moment. A considerable percentage of 

^ See p. 396. 



EXAMINATION OF THE URINARY APPARATUS. 405 

albumin is disturbing, because then the precipitation of the suboxid of 
copper [copper oxydule] either does not take place at all or not 
promptly. If this is the case, the albumin must first be removed. 

The principle is that in Trommer's test the copper oxid in an 
alkaline solution of grape-sugar is reduced to a lower state of oxida- 
tion : 5 parts of anhydrous grape-sugar will reduce 34,639 parts of 
pure copper sulphate to protoxid. The problem is to determine 
how much of a specimen of urine is necessary to reduce a certain 
amount of copper sulphate. 

Solution I. : 34,639 grams of pure copper sulphate are, by warm- 
ing, dissolved in about 100 grams of water, and the solution is then 
diluted to 500 c.c. It is to be set away, well corked. 

Solution II. : 173 parts of sodium tartrate and 100 parts of officinal 
solution of sodium hydrate of the specific gravity of 1034, dissolved in 
water to 500 parts. This is to be kept in a well-stoppered bottle, but 
it must not be allowed to become too stale. 

Mode of Procedure. — Mix equal parts of I. and II. The mixture 
(Fehling's solution) must not, when boiled, separate any oxydule. 
Ten c.c. of the mixture and 40 c.c. of water are placed in a deep 
porcelain saucer or in a little glass bulb. Thoroughly mixing the 
urine of twenty-four hours, we take a portion of this and dilute it 
with 9 parts of water (urine i, water 9), and with this we fill a burette. 
The mixture in the saucer is brought to the boiling-point, and into this 
the urine in the burette is allowed to flow : there occurs a separation 
of oxydule and oxydule hydrate, and the blue color of Fehling's solu- 
tion disappears. The instant when the fluid (if we incline the saucer) 
first completely loses its blue color shows the completion of the reduc- 
tion. We allow the amount of urine necessary to complete the reduc- 
tion to flow from the burette. 

Calculation. — Since 0.05 gram of grape-sugar reduces 10 c.c. of 
Fehling's solution, therefore the quantity of the mixture which has 
escaped from the burette contained 0.05 gram of grape-sugar. We 
represent that quantity of the mixture by q ; then the mixture in 

^u u ^^ . • 0-05 X 100 5 . . , 

the burette contams — =^ per cent, of sue^ar. And, 

since the mixture of urine was diluted tenfold, the urine itself contains 

5 X 10 50 , . . 

— - — = — per cent, sugar — that is, five times the amount diluted, 

divided by the quantity of the mixture in the burette that was used. 

The dilution of the urine is to be varied according to the amount of 
sugar it contains, which is to be done in such a way that the mixture in 
the burette shall contain about 0.5 to i per cent, of sugar. 

Schmiedeberg's Modification. — This is a modification of Fehling's 
solution which can be kept for a long time : a solution of CUSO4 34.64 
in distilled water 200.0 is mixed with a solution of mannit 16.0 to dis- 
tilled water loo.o. 

\yhen used, to this solution is added solution of sodium hydrate (i . 145 
specific gravity, 62.4 per cent, of NaHO) 480.0, and then water added 
to make 1 000.0. Mode of procedure and calculation is the same as 
above. 



406 SPECIAL DIAGNOSIS. 

A Method of Approximate Determination of Sugar. — For 

practical purposes the approximative method suggested by Duhomme 
is very useful. Its basis is the estimation by Fehling's solution, but 
requires two Limousin's drop-counters, one for i c.cm. and one for 2 
c.cm. In the former is placed exactly i c.cm. of the urine to be tested, 
and the number of drops contained in this c.cm. of urine is counted. 
Then by using the second drop-counter, 2 c.cm. of freshly prepared 
Fehhng's solution and an equal amount of water are put into a test- 
tube ; heat to boiling, add i to 2 drops of urine ; shake, again heat to 
boiling-point, add i to 2 drops more of urine, boil, and so continue, re- 
peating the process till the hquid is completely discolored. 

Calculation. — The number of drops of urine in i c.cm. divided by the 
number of drops used for the reduction, gives the percentage of sugar. 
For instance, i c.cm. of urine contains 20 drops. Thirty drops have 
been used : hence f-g- equals 0.7 ; that is, the urine contains 0.7 per 
cent, of sugar. 

Urine which contains a very large percentage of sugar must be 
diluted. 

2. Determining the Sugar by Circumpolarization. — This depends 
upon the property of sugar to turn the plane of polarization to the 
right. Recently, the method has come somewhat into discredit, or it 
has been shown to be exact only when we exclude oxybutyric acid 
and any levulose that may be present, both of which turn the plane of 
polarization to the left. Regarding complicated methods (complete 
fermentation, etc.), see hand-books upon Urine-Analysis. 

We do not give a description of the method by polarization, as a 
description of its use always accompanies the different apparatus sold. 
(We recommend particularly the simple apparatus made by Zeiss.) 

It must be remembered that urines containing albumin have to be 
de-albuminized (acidified by acetic acid and boiled), and those that are 
too dark have to be decolorized. The latter is done by adding .basic 
acetate of lead and ammonia till an abundant precipitation takes place. 
The filtrate is then sufficiently decolorized for polarization. 

OTHER SOLUBLE CONSTITUENTS OF THE URINE. 

I^evulose sometimes occurs in the urine, in addition to grape-sugar, 
in cases of diabetes meUitus. It gives the chemical reaction of the lat- 
ter, and for this reason it cannot, without complicated methods, be 
recognized, chiefly on account of a striking difference between the 
quantitative determination by Fehling's solution on the one side and 
the polarizing apparatus on the other. Levulose turns the plane to the 
left, but we must be on guard with reference to oxybutyric acid, which 
also turns the plane to the left. 

I/actose occurring in puerperal patients, inosite in diabetes insipidus 
and albuminuria, can only be demonstrated in the urine when they are 
isolated. 

I/ipuria, as has been already mentioned,^ occurs in chyluria. It 
has in one instance (Ebstein) been found in pyonephrosis ; small quan- 
tities of fat occur with large white kidney,^ in poisoning by phosphorus 

1 See p. 371. 2Seep. 378. 



EXAMINATION OF THE URINARY APPARATUS. 407 

and in diabetes mellitus, and also in health after taking very much fat, 
as cod-liver oil. The proof is by mixing it with ether. Lapaciduria 
(fugitive fatty acids in the urine) has recently been much studied, but 
thus far, from the standpoint of diagnosis, without significance. 

Diaceturia, resulting from acetoacetic acid in the urine (v. Jaksch), 
never occurs under physiological conditions. It is observed in diabetes, 
and especially in the severe forms, which then sometimes end in coma ; 
also in fever and as an independent disease (v. Jaksch) ; and both are 
apt to occur in children. Acetone ^ at the same time is always abun- 
dantly demonstrable in the urine. 

Diaceturia, especially if it occurs in adults, generally indicates a seri- 
ous condition. It is of considerable importance for judging of the 
severity of diabetes. Gerhardt's chlorid-of-iron reaction,^ which is 
characteristic of diaceturia, although not perfectly reliable, is signifi- 
cant for the severe forms of diabetes. If diaceturia is present, oxy- 
butyric acid^ is also present in the urine. But it is important to 
observe that the chlorid-of-iron reaction may fail, and yet oxybutyric 
acid be abundantly present in the urine. 

In diabetic coma, which to-day is almost universally regarded as an 
auto-intoxication by oxybutyric acid (Stadelmann, Minkowski), the 
chlorid-of-iron reaction is usually very distinctly present. Pronounced 
chlorid-of-iron reaction is also frequently a warning precursor of dia- 
betic coma. It is to be remarked, however, that chlorid-of-iron re- 
action (and odor of acetone) may exist for a long time in diabetic 
patients without there ever being coma, and, on the contrary, coma 
may occur without chlorid-of-iron reaction ever having been present. 

Von Jaksch supposes that the convulsions of children, so frequent 
in acute diseases, are always accompanied by diaceturia. 

Proof of diacetic acid is made by Gej'liardfs chlorid-of-iron reaction. 
Some solution of chlorid of iron is added, drop by drop, to the urine ; 
sometimes there occurs an abundant precipitate of phosphates, which 
must be removed by filtration ; then more iron chlorid must be added. 
If diacetic acid is present, the urine becomes a burgundy-red to deep 
dark-brown. The reaction is not entirely positive. If we wish to make 
certain we must observe the following directions : The test must be 
repeated with urine that has been boiled. Further, a portion of urine 
must be mixed with sulphuric acid, extracted with ether, and then the 
test repeated with the extract ; lastly, it must be examined for acetone.* 
Diaceturia is certainly present if, in the presence of the chlorid-of-iron 
reaction of fresh urine, i, the boiled urine shows no or only a slight 
chlorid-of-iron reaction ; 2, if the ether extract shows a chlorid-of-iron 
reaction which fades in the course of twenty-four hours at the longest ; 
3, if acetone is present at the same time (v. Jaksch). 

Oxybutyric Acid (/9-oxybutyric Acid). — This acid has acquired an 
extraordinary importance in the pathology of diabetes, since we know 
that it is found in the urine in the severe forms of the disease (Kiilz, 
Minkowski) ; that its presence and quantity in these cases are about 
parallel with the severity of the disease or to the excretion of sugar 
(Wolpe) ; and, finally, that in diabetic coma it is without exception 
found in very great quantities in the urine. It is scarcely any longer 

1 See p. 409. 2 See below. ^ See below. * See below, p. 409. 



408 SPECIAL DIAGNOSIS. 

doubtful that diabetic coma represents an auto-intoxication by the acid 
— an acid-intoxication (Stadelmann) in which the acid produces a 
poisonous effect by the absorption of alkaH from the blood. In addi- 
tion to diabetes, this acid has also been found in acute exanthemata, in 
scurvy, and in the state of starvation (abstinent lunatics). 

In order to understand the frequent but not regular coappearance 
of oxybutyric acid, of diaceturia, and of acetonuria, which will be men- 
tioned below, it is important to remember that diacetic acid is a product 
of oxidation of oxybutyric acid, and, further, that diacetic acid easily 
decomposes into acetone and carbonic acid. 

/3-oxybutyric acid turns the plane of polarization to the left, and its 
presence in diabetic urine becomes probable when, after the sugar has 
been removed by fermentation, the urine turns the plane of polariza- 
tion to the left. It is necessary, however, to see that no albumin is 
present. Albumin must be removed, if any is present, by boiling the 
urine after acidulation with acetic acid. Sometimes it is also necessary 
to decolorize the urine.^ 

The more exact quahtative and quantitative determination is dif- 
ficult, and does not belong to the province of this work. 

In close connection with the excretion of acid (Hallervorden, 
Stadelmann) stands the excretion of a substance with which the 
organism neutralizes the pernicious acids so long as it is able to do so 
— the excretion of ammonia. 

[The Translator adds here a summary of Stadelmann's observations 
upon " Diabetic Coma," as given in the Americmi Journal of the Medi- 
cal Sciences, taken from Deiitsch. med. Wochenschrift, 1889, No. 46: 

'' I. Diabetic coma, apart from accidental coma due to other causes, 
occurs only in the case of diabetic patients whose urine contains oxy- 
butyric acids. 

" 2. Almost equivalent in value with the recognition of oxybutyric 
acid is the determination of the amount of ammonia in the urine, while 
it is also far easier of performance. 

" 3. Diabetic patients with an excretion of ammonia of more than 
i-j3^ grams per day, are in danger of becoming severe cases of the 
disease. 

" 4. Patients excreting 2, 4, 6, and more grams of ammonia daily 
need constant watching by the physician, and are in constant danger of 
passing into diabetic coma. 

"5. If the determination of the presence of oxybutyric acid or the 
estimation of the amount of ammonia cannot be carried out, at least the 
chlorid-of-iron test should be made. If this gives a more positive reac- 
tion, oxybutyric acid is present in the urine, and the cases answer to the 
statements made in the third and fourth conclusions. The converse of 
this, however, is not always true, for there are cases of diabetes with 
oxybutyric acid in the urine, and even suffering from diabetic coma, the 
urine of which does not give the chlorid-of-iron reaction."] 

Ammonia in the Urine. — In normal urine it amounts to only 
about 0.5 to 0.8 pro die, but when oxybutyric acid appears it is in- 
creased proportionately. We must omit here the quantitative determi- 
nation of this substance. 

^ See p. 406. 



EXAMINATION OF THE URINARY APPARATUS. 409 

Acetone. — This is a product of normal, and of increased, de- 
composition of albumin, but traces of it are found in the urine in 
health. By acetonuria we understand an increase of this substance, 
and its presence is made known by the odor of acetone ^ if the excre- 
tion is abundant. Acetonuria is found in diabetes, sometimes in con- 
nection with diaceturia and excretion of oxybutyric acid, and hence 
sometimes in coma or as a precursor of it. However, abundant ace- 
tone also occurs without these other substances, and by itself it is 
w^ithout special significance. Moreover, it is found in gastric and in- 
testinal disturbances, in inanition, in carcinoma (also without inanition), 
and in psychoses. But there also seems, especially in gastro-intestinal 
disturbances, to occur an auto-intoxication from acetone in connection 
with acetonuria (v. Jaksch), which intoxication is accompanied by 
epileptiform spasms and other phenomena of cerebral irritation, or also 
by signs of depression, which in the cases hitherto observed have 
ended in recovery. Also in these cases acetone appeared in the urine 
without diacetic acid, while on the other hand, as has been mentioned 
above, diaceturia seems never to occur without simultaneous acetonuria. 

The exact test is complicated. Several methods have been given, 
which, if one wishes to be certain, it is best to employ simultaneously : 
I. Distil the urine with some phosphoric acid. Several cubic centi- 
meters of this distillate are mixed with a few drops of solution of 
iodin and potassium iodid : an immediate precipitate of iodoform-crystals 
proves the presence of acetone (Lieben). 2. We add to the urine some 
freshly-prepared mercuric oxid, obtained by mixing an alcohoHc 
solution of potash with mercuric chlorid. Filter it, and cover the 
filtrate with ammonium sulphate : a black ring of sulphate of mer- 
cury shows acetone (Reynolds). Legal (cited by v. Jaksch) has devised 
a test for acetone which is a useful preliminary one : Several cubic 
centimeters of urine are treated with a few drops of a concentrated 
solution of sodium nitro-prusside and somewhat concentrated liquor 
potassse. If acetone be present, a bright-red color is seen, which 
quickly fades, but upon the addition of some acetic acid changes to 
purple or violet-red. 

Regarding the occurrence in the urine of paired sidpJiuric acids or 
of the products of their decomposition (here also belong indican, which 
has been previously mentioned, indoxylsulphuric acid), also of ptomains, 
ferments (especially pepsin), see the various special works upon these 
subjects. 

i^hrlich'S Diai^O-reaction. — Some years ago Ehrlich discovered 
that by means of diazo combinations aromatic bodies could be demon- 
strated in the urine. The chemical nature of these substances is still 
unknown. They may be regarded as products of decomposition which 
appear only in certain conditions and are excreted with the urine. The 
reaction which takes place in the presence of such substances he calls 
diazo-reaction. 

Mode of Procedure. -^The reagents must be freshly prepared each 
time, and consist of the following : 

I. 250.0 of highly diluted hydrochloric acid, saturated with sulfanilic 
acid (HCl 50.0; aq. destillat. lOOO; sulfaniHc acid 5.0). 

1 See p. 373. 



4IO SPECIAL DIAGNOSIS. 

2. 5.0 of a 0.5 per cent, solution of sodium nitrite. 

The mixture may be very well made by putting 3 grams of No, I in 
a test-tube and adding i drop of No. 2. 

Next, mix equal parts of urine and the reagent, and add somewhat 
quickly (not drop by drop) an excess of ammonia (about one-eighth 
volume). If the mixture assumes a red color, the diazo-reaction is 
present. The reaction occurs in different degrees, from hght pink to 
deep red. The foam which forms from shaking shows the color very 
distinctly. Healthy urine, without exception, after this treatment takes 
a brown-yellow color. 

In diseases without fever the diazo-reaction is only very seldom ob- 
served ; and the same is true of chronic severe cachectic conditions of 
the most varied character. Here it has no diagnostic value. 

But among the diseases with fever there are some to which it par- 
ticularly applies. For example, it is almost always present in typhoid 
fever, except in very light cases. It occurs with typhus exanthematicus 
and in measles. It would therefore be of weight in deciding a doubtful 
case of typhoid fever, were it not also frequent in another disease which 
has often to be considered in doubtful cases of typhoid fever — namely, 
in acute miliary tuberculosis. For the diagnosis of recurring typhoid 
fever a positive result of the test has some decided value, particularly 
in differentiating it from other feverish complications of convalescence 
from typhoid fever, in which it is always absent, as in intestinal catarrh. 
Moreover, the reaction is also frequent in severe florid phthisis. 

A prognostic value of the diazo-reaction obtains in typhoid fever, 
where its disappearance seems to signify a favorable result, and in 
phthisis, where its appearance is ominous. 

THE URINE AS AFFECTED BY MEDICINES AND POISONS. 

The determination as to whether a medicine has been taken or not 
may often be of diagnostic importance. A number of medicines may 
be directly detected in the urine : to those not easily or not at all de- 
monstrable, according to Penzoldt's recommendation of a particular 
case, we add one easily demonstrable, even if given in small amount. 
The one most available for the purpose is an iodin salt (about o.i to 
0.2 iodid of potash). If we find in the urine the reaction of demonstrable 
medicines that have been given, then we can naturally assume that any 
other which was mixed with it has been taken. 

The urine has only a limited significance for the detection of poisons 
— in the first place, because they are excreted to so limited an extent 
as to show only a trace, or are not given off in a form to be detected. 

We give here a few short directions : 

Preparations of Iodin. — Add a couple of drops of red fuming 
nitric acid and about one-quarter as much chloroform as there is of 
urine ; shake it gently ; the chloroform gradually settles colored red- 
dish-violet. 

Bromin. — The same method ; chloroform colors it brown-yellow. 

Salicylic Acid. — The urine is made a blue-violet by the chlorid 
of iron (not burgundy-red).^ When the amount of salicylic acid is 

1 See Diaceturia, p. 407. 



EXAMINATION OF THE URINARY APPARATUS. 411 

small, we shake up the urine (to which some sulphuric acid has been 
added) with ether, and then apply the test. 

Rhubarb and Senna. — See page 371. 

Carbolic Acid, Naphthalin, Resorcin, etc.— The urine con- 
tains hydrochinon, and after standing for a time becomes olive-green 
to brown-black, even black. Exact determination requires peculiar 
methods. 

Salol. — Urine containing this, as well as carbolic acid, becomes 
green to black, and at the same time responds to the tests for salicylic 
acid. 

Antifebrin. — Add one-fourth volume of a concentrated solution 
of hydrochloric acid in a reagent-glass ; boil for a few minutes ; cool ; 
add a few c.c. of a 3 per cent, solution of carbolic acid and a drop of 
dilute solution of chromic acid. The mixture becomes red ; after the 
addition of ammonia up to an alkahne reaction, a beautiful blue (after 
Miiller). 

Antipyrin, Thallin. — Red coloration with chlorid of iron ; more- 
over, thallin urine is green-brown. 

Of the poisons, properly so called, arsenic, antimony, and lead, 
they pass off by the urine in very small amounts. This is true also 
of mercury and silver, but the former after long administration may be 
demonstrated without difficulty. We refer to the text-books upon 
toxicology. Of the alkaloids, quinia and strychnia are excreted in 
part unaltered ; morphin also sometimes, but sometimes it is absent 
altogether. Also here we must refer to works devoted exclusively to 
toxicology. 

EXAMINATION OF THE SECRETIONS OF THE MALE 
QENITO=URINARY APPARATUS. 

Although with reference to the examination of the genital organs 
themselves we refer to the text-books upon surgery and sexual dis- 
eases, as may be seen from the superscription, we confine ourselves 
here to a consideration of the character of the secretions so far as this 
has a bearing upon diagnosis. 

The normal seminal fluid is a mixture of the secretions of the 
testicles, the vesiculse seminales, the prostate, and the glandulae Cow- 
peri (Fiirbringer). It is a ropy, viscid mixture of mostly fluid and 
some compact substances resembling swollen groats. It is whitish in 
color, of a neutral to weakly-alkaHne reaction, and has a peculiar 
characteristic odor. Microscopically, it contains large quantities of 
spermatozoa, some finely granulated testicle-cells of different size, and 
roundish grains, so-called prostatic granules. If some of the sper- 
matic fluid be dried, there are formed the so-called sperma-crystals, 
large, light, oblong crystals, which are a product of the prostatic epi- 
thelia, as Fiirbringer has shown. They have a certain superficial resem- 
blance to Charcot's crystals, which we have met with in sputum, in 
feces, in leukemic blood, and in other places. According to exact 
crystallographic examinations, however, they are not identical with 
these (Cohn). 

The sperma-crystals may be demonstrated in a particularly beau- 



412 SPECIAL DIAGNOSIS. 

tiful manner by adding to the sperma upon an object-slide a drop of 
a I per cent, solution of ammonium phosphate and examining at the 
edge of the cover-glass after it has stood for several hours. 

According to our present knowledge, the chemical composition 
of the sperma does not come into consideration for the purposes of 
diagnosis. 

It is of interest to distinguish the individual constituents of the 
sperma according to their different origin : 

1. The pure secretion of the testicles, according to examinations 
made in animals, is a homogeneous, viscid, whitish liquid which can be 
drawn out in threads. It furnishes the spermatozoa and testicle-cells 
of the sperma. The spermatozoa show a very lively individual move- 
ment in the fresh sperma. 

2. The unmixed secretion of the seminal vesicles is gelatinous, 
slightly yellow, resembles swollen sago-grains, and furnishes the grit- 
like constituent of the sperma. When the sperma is not quite fresh 
these granules quickly dissolve. 

3. The normal secretion of the prostate may be obtained by a 
digital compression of the gland through the rectum. It is a thin 
fluid, made milky-turbid by peculiar microscopic granules and strati- 
fied amyloid bodies. When mixed on a glass slide with a drop of a 
I per cent, solution of ammonium phosphate, and then evaporated, it 
forms the sperma-crystals.^ 

The abnormal character of the spermatic fluid has nothing 
to do with a diagnosis of ivipotentia coeundi — that is, as regards in- 
ability to cohabitate — for this condition occurs quite independently 
without any abnormality of the sperma ; and, on the other hand, 
anomahes, and even entire absence of sperma, by no means excludes 
the ability to cohabitate. 

It is necessary to distinguish — 

1. Aspermatism. — This is a condition where during ejaculation 
there is no discharge whatever from the urethra. It is very rare, and 
is generally caused by stricture of the urethra or the openings of the 
ductus ejaculatorii. In stricture of the urethra the sperma flows back- 
ward into the bladder, later is forced through the stricture with the 
urine. Or the sperma may not pass during erection, but after the 
penis has become relaxed — that is, after cohabitation. The nature and 
location of the stricture must be ascertained by a careful local exam- 
ination, possibly by means of an endoscope (Nitze). The most com- 
mon conditions are: stricture from gonorrhea, diseases of the pros- 
tate, anomalies of the location and form of the colliculus seminalis. 
Moreover aspermatism has been observed with spinal diseases. 

The so-called temporaij, relative aspermatism (temporary absence 
of ejaculation, dependent upon sympathy, inclination for certain 
women) is considered by Fijrbringer and Giiterbock as related to, or 
identical with, psychical impotence. 

2. Azoospermia. — There is seminal fluid, but it contains no sper- 
matozoa. This is much the more frequent form of sterility. The 
spermatic fluid nevertheless has the characteristic odor, very often it 
is in all other respects similar to normal, lacking only in spermatozoa. 

^ See preceding page. 



EXAMINATION OF THE URINARY APPARATUS. 413 

There may be no other possible anomaly of the genital apparatus or 
possible disturbance of the potentia coeundi. This is true of the 
majority of cases. 

Azoospermia mostly depends upon obliteration of the seminal 
ducts, especially from epididymitis or funiculitis duplex as the result of 
gonorrhea. Moreover, it may be due to other severe diseases of the 
testicle — syphilis, tuberculosis, malignant tumors, congenital rudimen- 
tary development, etc. 

There have been some cases of temporary azoospcinnia observed ; it 
may sometimes happen after very excessive abusus sexualis, and hence 
a single observation of absence of spermatozoa must be taken into 
account with caution. 

Immobility of the spermatozoa in a fresh ejaculation or their 
deformity cannot, according to our present knowledge, with certainty 
be used for the diagnosis upon one or the other side. 

Method of Determining Aspermatism or Azoospermia. — The best way 
is to require the use of a condom in cohabitation. The contents of the 
condom should be examined as soon after the cohabitation as possible. 
It is conceivable that there are cases where the secretion cannot be 
obtained in this manner, but the other '' method," closely approxi- 
mating this, is not only disgusting, but, in our opinion, the results 
might not always be convincing. There are numerous difficulties in 
this connection, and for further details of this question we refer to 
Fiirb ringer's KrankJieitcn dcr Harn-tind GescJilechtsorgane. 

The conditions hitherto described can only be distinguished by 
microscopical examination. This is also the case where evacuations 
of sperm-like fluids from the urethra take place at other times than 
during coitus. We distinguish the following: 

1. TJrethrorrhoea ex I/ibidine (Fiirbringer). — During erection, 
but without signs of ejaculation, a few drops of a liquid resembling 
egg-albumin, and containing only a few epithelia and round-cells, 
escape from the orifice of the urethra. Probably they are the secre- 
tion from Cowper's, possibly also of Littre's, glands. The condition 
is in itself without significance, but sometimes it is not easily distin- 
guished from chronic gonorrhea.^ Besides, urethrorrhcea ex libidine 
produces in the urine no forms similar to the gonorrheal threads, 
but its product floats in the urine as transparent jelly-like formations 
(Fiirbringer). 

2. Prostatorrhea. — This is an evacuation of normal prostatic 
secretion or of a thick fluid, mucous or muco-purulent discharge, 
sometimes constant, sometimes temporary, and again often passed 
during defecation or urination. The microscope shows pus-corpuscles, 
etc., as characteristic elements, amyloid bodies, and after evaporation, 
sometimes only after addition of ammonium phosphate,^ Bottcher's 
crystals. Prostatic secretion sometimes causes threads in the urine 
similar to the gonorrheal filaments. Moreover, it is necessary to 
remember that chronic gonorrhea may exist at the same time. 
Prostatorrhea occurs with chronic prostatitis, both diffuse and sup- 
purative. 

Both with urethrorrhcea ex libidine and with prostatorrhea it is 

See this. ^ See above. 



414 SPECIAL DIAGNOSIS. 

possible that sometimes there may be admixture of individual sper- 
matozoa. 

3. Spermatorrliea. — The spermatic fluid may be passed without 
erection, most frequently during defecation, also at the close of urina- 
tion or in walking, marching, climbing, etc. It may be perfectly 
normal or thinner than normal, or it may be mixed with pus or blood. 
These genuine pathological losses of semen occur in tabes and other 
spinal diseases ; in epilepsy, insanity ; in neurasthenic cases, especially 
those following excessive venery, but especially those due to mastur- 
bation. 

The diagnosis of urogenital tuberculosis and gonorrhea has been 
treated of in the chapter on Urinary Apparatus, pages 383 and 384. 



CHAPTER VIII. 
EXAMINATION OF THE NERVOUS SYSTEM. 



Science has not revealed in any organ of the human body an ana- 
tomical structure so fine and complicated as exists in the different parts 
of the nervous system. Nowhere else can be found tissues which differ 
so entirely and which are so clearly distinguishable clinically as here. 




Fig. 154. — Convolutions and sulci of the surface of the hemisphere of the brain. 

It is not easy to acquire a knowledge of its anatomy and physiology, 
but its study rewards the diagnostician in an extraordinary manner, for 
in no other domain of pathology can he with such certainty make a 
diagnosis which, on the one hand, is based on the anatomical rela- 
tions, and, on the other, on loss or alteration of functions. To the 
purely scientific satisfaction of making a correct diagnosis is, in many 
cases, added the most important practical element, the discovery of 
means of cure. For, although hitherto some of the diseases of the 
nervous system have been little accessible to treatment, nevertheless, 
there are some in which everything — life, ability to earn a living, and 
general well-being of the patient — depends upon correct treatment. 
Practically, here, more than anywhere else, the principal problem for 
the diagnostician is that among the marvellous variety of the phenom- 
ena of disease he recognize with a clear vision those which offer a favor- 
able prospect for treatment. This demand is at the present day still 
often unsatisfactorily fulfilled. 

415 



4i6 



SPECIAL DIAGNOSIS. 



PRELIMINARY REMARKS ON ANATOMY AND NORMAL AND 
PATHOLOGICAL PHY5I0L0QY. 

Nothing- more than a sketch of what is most important can be given 
here. For more exact studies I refer to Edinger's well-known excellent 
work.^ 




Fig. 155. — Localization of the cortex of the left hemisphere (after Edinger). 

Without dwelling upon the general anatomy, we enter at once upon 
those parts of the nervous system which are specially concerned in 
diagnosis. 



I. The Motor Tracts and Centers. 

The motor tract for all regions of the body is divided into a central 
and peripheral one. 

The ce7itral motor tract, the pyramidal tract, originates in the motor 
(the psychomotor) centers of the cortex of the cerebrum. These latter 
unite in the upper two-thirds of the so-called motor-cortex field, which 
includes the upper central convolutions and the lobus paracentralis of 
both hemispheres. 

Fig. 154 shows the surface of the left hemisphere, with the names 
of the convolutions and' the sulci. 

From Fig. 155 may be seen where the muscular system of the face 
(tongue and eyes), of the larynx, of the trunk, and of the extremities 
has its origin within the motor zone. 

And now to bring out the most important features : The center for 
the larynx, the hypoglossus, and the lower facial is situated in the lowest 
portion of the anterior central convolution, near the speech-center (the 
center of the anterior facial has not yet been positively made out) ; 
close to this, mostly in the anterior central convolution, is located the 
arm-center, and in such a way that its lower part presides over the 
distal part of the extremity ; in the upper part of the anterior and pos- 

1 Bau del' Nervosen Centra lorgane, 5 Auflage, Leipzig, F. C. W. VogeL 



EXAMINATION OF THE NERVOUS SYSTEM. 



A^7 





terior central convolution and are the lobiis paracentralis is situated the 
center for the leg. 

It will be noticed that the centers are tolerably wide apart, as is also the 
case with the tracts which originate from 
them and radiate into the medullary layer. 
Farther down the tracts converge in 
the corona radiata, in a fan-shape, to the 
internal capsule, where they lie close to- 
gether in its posterior peduncle — that is, 
between the lenticular nucleus and optic 
thalamus : they lie close together be- 
hind a point midway between these [but 
do not connect with them]. Farther on 
they reach to the foot of the crus cerebri, 
and pass about in the middle of it. In the 
pons the pyramidal tracts are split up by 
transverse fibers. They unite again to 
form pyramids at the anterior portion of 
the medulla oblofigata, and here the 
pyramidal tracts of both sides of the 
middle line lie very closely together. 
[From the circumstance that they form 
the anterior pyramids of the medulla 
they receive their name, " pyramidal 
tracts."] In the lower decussation of the 
pyramids of the medulla oblongata the 
right and left pyramidal tracts interlace, 
so that very much the larger part of the 
fibers go to form the lateral column of 
the opposite side of the spinal cord {lateral 
pyramidal tracts Py-L). Only a small 
part of the fibres [of the external aspect 
of the pyramids], without crossing to the 
opposite side, pass to the anterior column 
of the spinal cord [forming the columns 
of Tiirck]. {Anterior pyramidal tracts, 
Py-V) 

At different levels of the cord, from 
the lateral pyramidal tracts, successive 
fibers continually connect with the gan- 
glion-cell groups of the anterior horn of 
the same side, and from these ganglion-cells arise the anterior roots of 
the [nerves of the] spinal cord. These unite with the posterior and 
form with them the mixed peripheral nerves. In these the motor 
tracts pass to the muscles. 

The path of the motor cerebral nei'ves from the cortex to the nuclei 
of the pons and oblongata is not known, except that of the lower facial 
and the hypoglossus. The fibers for the former^ pass from the cortical 
center obliquely across the lenticular nucleus to the internal capsule, 
where they lie close to the pyramidal tract. They pass with the latter 




Fig. 156. — Diagram of the innerva- 
tion of the muscles (partly from 
Edinger). 

The radiation of the /^-tracts varies at 
different portions of the cortex (see text) : 
Py-H, pyramidal tract for the cervical 
spinal cord ; Py-L, pyramidal tract for the 
lumbar portion of the cord ; H, cervical 
cord; L, lumbar cord; Py-V x'-, omitted. 
Notice that down to the lumbar portion of 
the cord Py-L passes in the lateral column. 



27 



Compare Fig. 157. 



4i8 



SPECIAL DIAGNOSIS. 



through the foot of the cerebral peduncle, but separate from it above 
the pons to reach the decussated facial nucleus in the lower part of the 
pons (Edinger). The hypoglossiis tract runs near the speech-tract, 
likewise to the inner capsule, where it probably comes to lie between 
the fibers of the facialis and those of the extremities. In the pons it 




wr. Fa. w. 

Fig. 157. — Location of the nuclei of the cranial nerves (Edinger). 

The oblongata and pons are represented as transparent. The nuclei of sensation are red, those of motion 

are black. 



separates from the pyramidal tract, and in the oblongata goes to the 
twelfth nucleus of the other side. 

The tract for the co-ordination of speech has been determined for 
only a certain portion of its length. It runs from the third frontal 
convolution (" sermo " in Fig. 155), below the island [of Reil], almost 
horizontally to the internal capsule near its knee, and from there to the 
foot of the crus cerebri, to separate in the pons from the pyramidal 
tract and to end in the seventh and twelfth nuclei. 

The peripheral motor tract is the designation given to the portion 
from the ganghon-cells of the anterior-horn ganglia or from the cells 
of the gray nuclei of the pons and oblongata through the motor cere- 
bral and spinal nerves to the muscle end-plates. The nuclei and tracts 
of the cerebral and spinal nerves are known exactly throughout their 
courses. Fig. 157 illustrates the location of the nuclei in the pons 
and oblongata, represented as transparent. This figure, taken from 
Edinger's work, is admirably adapted for locating diagnostically these 
centers when they are the seat of disease. 

The cerebral nerves in part have a complicated course among the 
peripheral nerves. In the first place, it is essential to observe that they 
may enter into local relation with different parts of the brain, not only 
at the place of their egress from the brain, but also in their course at 
the base of the brain, and may therefore participate in diseases, particu- 
larly tumors, at the base. This is the case with the facialis after its 
exit on the floor of the fourth ventricle, close to the lower surface of 
the cerebellum, and with the hypoglossus, which runs laterally upward 
beside the oblongata. The trigeminus penetrates the basal lateral 
part of the pons ; the oculo-motorius penetrates the cerebral peduncle 



EXAMINATION OF THE NERVOUS SYSTEM. 419 

and lies close to its base for a considerable distance more, etc. More- 
over, it is of diagnostic interest to observe how the cerebral nerves at 
the base enter into relations among themselves by reason of their 
juxtaposition. Upon this point Fig. 159 gives satisfactory illustration. 
Finally, there also comes into consideration the manner in which the 
nerves enter the bony canals at the base of the skull, and partly also 
outside of it. 

The center's of tJie cortex are those of voluntary motion. They 
transmit the stimulus through the fibers of the corona radiata or of the 
pyramidal tract respectively, to the nuclei of the oblongata or the ante- 
rior columns respectively, and these in turn transmit the irritation on 
through the peripheral nerves to the muscles. But likewise the nuclei 
of the peripheral motor tract are simultaneously reflex centers ; that is, 
they transpose sensible stimuli transmitted from the periphery into 
motor stimuli for the muscles belonging to them, and they are also 
trophic centers for the peripheral motor nerves and the muscles ; that 
is, they preside over their nutrition. 

The cutting out of the cortical center or the interruption of the 
central motor tract belonging to them renders voluntary movements 
in the respective muscular region impossible — a paralysis of voluntary 
movements. At the same time, the respective muscles remain under 
the influence of reflex stimuH. and their nutrition also for the most part 
remains normal, since the nuclei pertaining to the peripheral motor 
tract continue to perform their function. On the contrary, the reflexes 
and tonus of the muscles usually are increased, and hence these paral- 
yses in general are called spastic paralyses. 

If, however, the nuclei of the peripheral tract are destroyed or the 
fibers going from them are interrupted, the appertaining muscles are 
completely paralyzed ; that is, they are excitable neither through the 
will nor through the reflexes, they immediately lose their tonus, and 
they degenerate, because their trophic stimulus is removed. Only 
mechanical and electric — that is, galvanic — stimuli, which directly act 
upon the muscular fibers, produce unnaturally slow contractions. These 
paralyses (ituclear and peripheral paralyses) are therefore correctly 
called " atonic degenerative paralyses!' 

Both of these kinds of paralysis are of great significance for diag- 
nosis, because we are able immediately to distinguish whether a lesion 
has affected a central or a peripheral motor tract. For the more exact 
determination of the seat of disease it is necessary in the first place to 
ascertain the location of the paralysis and its possible combination with 
disturbances of the sensible sphere, with other signs on the skull, 
spinal column, extremities, etc. 

2. The Sensitive or Centripetal Tracts. 

The tract of the voluntary arid involuntary sensibility of the skin of 
the trunk and of the extremities passes from the sensitive terminal fibers 
of the skin in the mixed nerves, then into the posterior root to the cord. 
Until a very short time ago very little was known of its continuation 
upward. More recent investigations, however, especially Edinger's 
excellent works, have shown that it gives two (possibly more) processes 



420 SPECIAL DIAGNOSIS. 

to the posterior root — one which ascends without decussating in the 
posterior columns to the medulla oblongata, and there, by interlacing 
fibers fi-om ganglia (posterior column ganglia), enters the decussated 
loop [or crossed fillet] (lemniscus), and thence into the deep medulla 
of the corpora quadrigemina. A second process enters the spinal-cord 
ganglia — namely, those belonging to the gray posterior horns, the end- 
nuclei of the peripheral sensible tract. From these end-nuclei arises 
the ce7itral sensitive tract, which partly crosses directly and partly 
higher in the spinal cord through the anterior commissure, and 
reaches the anterior and lateral column on the opposite side as the 
tractus tecto-spinahs, to pass to the loop (lemniscus), and to pass with 
this to the corpora quadrigemina. For a still farther distance we know 
the course of the sensible tract in the brain, for we know that it enters 
through the tegmentum of the cerebral peduncle into the inner capsule, 
behind the pyramids ; that is, into the posterior third of its posterior 
peduncle. We have no positive knowledge of its distribution upward 
beyond this point. 

The tract of deep sensibility (usually called the muscular sense) 
seems to run in the posterior columns. Most probably it ends in the 
motor cortical zone of the central convolutions and the lobus para- 
centralis. 

Moreover, the lateral colum7z of the tract of the cerebelhun is cen- 
tripetal, which, arising from the columns of Clarke, in the upper por- 
tion of the cord, goes into the cerebrum. Its function also is not 
entirely clear; probably it is of service in preserving equilibrium. 

Severe lesions, or complete interruption of the tract of sensibility of 
the skin in the peripheral nerves or in the cord or in the internal 
capsule, causes total anesthesia of the skin. If the lesion is not severe, 
there is diminution of the sense of touch or a partial loss of sensibility 
— a partial paralysis of sensibility, as the sense of pain, of eold, of heat ; 
and this latter is frequent, especially in diseases of the spinal cord. 
Anesthesia from local disease of the internal capsule or of the spinal 
cord manifests itself upon the opposite side. 

3. Centers and Tracts of the Special Senses. 

(a) Sight. — This tract passes from the retina in the eye to the 
chiasm. Here occurs a peculiar partial decussation (semi-decussation), 
which is reproduced in Fig. 158: the optic-nerve fibers belonging to 
the outer half of the retina do not cross, those belonging to the inner 
half do. Then it passes in the optic tract to the anterior corpus quad- 
rigeminum, and from there in the posterior third of the posterior 
limb of the internal capsule entering into relation with the pulvinar of 
the optic thalamus and the corpus geniculatum ext., and then spreads 
out obliquely backward and upward in the cortex of the occipital 
lobe. The most important points in relation to this nerve are the 
following : 

I. That pathological processes at the base of the brain, and also 
lesions in the posterior end of the inner capsule (causing a simultaneous 
hemianesthesia), lastly, of the pulvinar of the optic thalamus, or of the 
occipital lobe, produce disturbances of vision. 



EXAMINATION OF THE NERVOUS SYSTEM. 



421 



2. That every complete destruction of the cortical centers in the 
occipital lobes, as well as of the tract from there to the chiasm, cuts 
off the impressions of sight from 
the outer half of the retina of the 
same side and the inner half of 
the opposite, thus from synony- 
mous halves of the two retinae. 
Thus, hemiopia and hemianopsia 
are produced.^ 

{b) Hearing.— The acoustic 
nerve, together with the facial, 
passes to the oblongata, etc., to 
the acoustic ganglion, in regard 
to which we cannot here enter into 
further detail. In its central course 
the auditory tract hes in the tegu- 
mentum of the opposite cerebral 
peduncle, and then appears prob- 
ably in the most posterior sensi- 
tive portion of the internal capsule. 




Fig. 158. 



-Diagram of the optic -nerve fibers 
in the chiasm. 



^hence it radiates in the cortex of 



the temporal lobe.^ It is also connected with the cerebellum, 

(<f) Smell. — Of the olfactory nerve perhaps nothing more is to be 
said than that its centripetal tract seems to pass through the posterior 
portion of the internal capsule. 

{d) Taste. — The sense of taste is located [chiefly] in the glosso- 
pharyngeus nerve, distributed to the palate and the posterior third of 
the tongue, by which nerve it is conveyed to the oblongata. The 
course for the anterior two-thirds, however, is comphcated : as the 
chorda tympani it first passes in the Hngual nerve, but leaves this and 
goes to the facial, leaves this again at the geniculate ganglion, and 
probably extends, as the greater superficial petrosal nerve, Vidian, and 
the spheno-palatine ganglion, to the second branch of the trigeminus, 
going with this toward the center, or through the otic ganglion to the 
third branch of the fifth nerve (Ziehl). We again meet the fibers of 
taste in the posterior portion of the inner capsule. 

It is very important in peripheral paralysis of the facial to note the 
participation of the sense of taste at the anterior portion of the tongue, 
and also (according to Erb and others) in disease of the trigeminus 
situated near its origin, as well as in lesions of the posterior portion 
of the inner capsule (hemianesthesia). 

Until we come to the Symptomatology we delay speaking of all 
other points regarding localization of the brain, especially regarding 
aphasia and the phenomena associated with it, and regarding the origin 
of certain forms of convulsions, of vertigo, co-ordination, etc. 



4. Remarks upon the Vessels Supplying the Brain. 

The brain is supplied with blood from the two internal carotids and 
from the vertebral artery. The right and left vertebrals unite at the 
basilar surface of the pons to form the basilar artery ; this, again, 

^ See under Eye. ^ See Word- deafness. 



422 SPECIAL DIAGNOSIS. 

divides at a point corresponding to the anterior inferior border of the 
pons into the two posterior cerebral arteries, which, by the posterior 
communicating arteries, form a connection with the carotids ( the circle 
of Willis). Besides the ophthalmic and the posterior communicating, 
the carotid gives off the anterior communicating, which, with its oppo- 
site fellow, completes the circle of Willis. There also arises from the 
carotid the middle cerebral, the [largest and] most important vessel of 
the brain. 

Of these vessels the greatest interest attaches to those which supply 
the pons and medulla and the most important part of the cortex and 
the internal capsule. 

The pons and medulla are chiefly supplied by the basilar and verte- 
brals. The branches of these are terminal arteries ; that is, they do 
not anastomose with each other or with other branches in their neigh- 
borhood. Hence, thrombosis or emboli of such branches — or, for 
instance, of a part of the basilar — immediately produces arrest of func- 
tion, and if this arrest continues for a time — that is, unless the stoppage 
is soon removed — there follows anemic necrosis of the affected portion 
of the pons or medulla. 

The region of next importance is that supplied by the middle cere- 
bral artery (the artery of the fossa of Sylvius). This, as well as the 
regions of the cerebrum supplied by each of the two other arteries sup- 
plying portions of the cerebrum, divides distinctly into two parts, which 
do not anastomose with each other into an inner and a cortical portion. 
The inner region, supplied by the middle cerebral artery and its branches, 
embraces the internal capsule, with the exception of its posterior sec- 
tion (sensory tract), the lenticular nucleus, the greater part of the cau- 
date nucleus, and a part of the optic thalamus. This internal region of 
the middle cerebral artery (artery of the fossa of Sylvius) is sharply dis- 
tinguished from the neighboring regions of the other arteries of the 
brain : there are no anastomoses ; hence, continuous occlusion of this 
vessel at its root must inevitably result in softening of the above-named 
central portion of the brain. The cortical region of the middle cerebral 
artery extends over the third frontal convolution, the anterior central 
convolution (with the exception of the upper portion, which belongs to 
the anterior cerebral artery), the posterior central convolution, the su- 
perior and inferior parietal lobes, the whole region in the neighborhood 
of the fissure of Sylvius; lastly, the second and third temporal convo- 
lutions. This cortical region of the artery of the fossa of Sylvius seems 
to anastomose in a very distinctive way with the neighboring cortical 
regions ; for this reason occlusion of the middle cerebral artery in only 
a part of the cases results in softening of this cortical portion of the 
brain. 

The optic center of the occipital lobe, the corpora quadngemina, 
and the posterior portion of the internal capsule are supplied by the 
posterior cerebral artery. 

The predominant importance of the middle cerebral artery consists 
not only in the fact that it supplies the most important portion of the 
cerebrum, but also because it is within this region that both hemorrhages 
and emboli most frequently occur. These two disturbances chiefly affect 
the internal region of the artery — the hemorrhages probably because 



EXAMINATION OF THE NERVOUS SYSTEM. 423 

the pressure is highest in the branches that go directly off from its root, 
or that here is felt most strongly the rapid changes in the power of the 
heart ; but emboli much more frequently disturb the inner territory 
than the cortical, because, as was mentioned before, there are no anas- 
tomoses in the former region, while in the cortical there are. In the 
relation of the left carotid to the aorta (going off at a very acute angle) 
seems to lie the explanation as to why emboli are much more frequent 
in the left middle cerebral artery than in the right. 

5. Topographical Diagnosis of Diseases of the Brain and Spinal 

Cord. 

Local diseases of the brain, whether hemorrhages, softening, local 
inflammation, cysts, abscesses, or tumors, cause symptoms which may 
in general be divided into two classes : one class form the local symp- 
toms — that is, those which occur in such a way that the local disease 
functionally damages a certain definite circumscribed portion of the 
brain ; and, secondly, the general phenomena which proceed from a 
more or less uniform injury of the whole brain, especially by concussion 
and by increased intracranial pressure. 

The local symptoms are divided into direct and indirect, or local 
symptoms and neighboring symptoms (Edinger). The direct local 
symptoms arise from destruction of functionally important portions of 
the brain or of parts whose functions cannot be performed by others. 
Indirect local symptoms are caused by temporary injuries or those 
which maybe recovered from. The injuries often change: the damage 
which the real focus produces falls upon the tissue immediately about 
it, but often also at a great distance from it. These injuries, passing 
beyond the original focus of injury, result from commotion produced 
by cerebral hemorrhages, from congestive states, in tumors of the brain, 
which cause the tumor to enlarge and thus give rise to pressure-anemia 
in the neighborhood ; likewise by hyperemia, hemorrhage, collateral 
edema, etc., according to the nature of the local disease. 

The direct local symptoms are always persistent unless, after a long 
space of time, a compensation of the omitted functions is made up by 
practice. Irritation phenomena — as, for instance, dissociated spasms 
of neuralgia — are, strictly speaking, never direct local symptoms, for 
they never occur other than only temporarily. 

Indirect local symptoms are partly phenomena of irritation and 
partly of defective function, and they may disappear altogether or only 
partly. From such changing symptoms not infrequently permanent 
ones may develop from the neighborhood of the focus of injury, and in 
this way they come into the class of direct local symptoms. This latter 
phenomenon occurs especially in tumors. 

General phenomena are sudden shock-like conditions, as in apoplexy 
or slowly developing symptoms of pressure. They consist of disturb- 
ances of consciousness, attacks of dizziness [vertigo], unlocalized head- 
ache, obtusion of the sensorium, of amnesia with respect to answering 
questions or slowness of speech; in short, general dulness (''stupor"), 
sometimes also a sort of marasmus ; general epileptiform spasms ; 
vomiting; retardation of pulse; lastly, the extremely important symp- 



424 



SPECIAL DIAGNOSIS. 



torn of choked optic disk, resulting in subsequent atrophy of the optic 
nerve. 

In local diseases of the spinal cord the general phenomena usually do 
not play an important role, and we are not able sharply to separate 
direct from indirect local symptoms. 

The following facts are essentially determinative in judging of the 
local symptoms : 

I. If the lesion is located in the cortex in the central motor tract 




Fig. 159. — Points of exit of the cranial nerves from the skull (Henle). 
The Roman figures indicate the cranial nerves ; V^, V"^, V"^, first, second, and third branches of the trigeminus ; 

V*, Gasserian ganglion. 

above the point of decussation, then the paralysis is upon the opposite 
side of the body ; lesion of a tract below its decussation produces par- 
alysis of the same side. It is to be pointed out that the central motor 
tract for the trunk and extremities decussates rather closely together 



EXAMINATION OF THE NERVOUS SYSTEM. 425 

in the decussation pyramid, while the tracts of the motor cerebral 
nerves decussate higher up, the facial tract about in the middle of the 
pons, and the hypoglossus tract in the oblongata. Hence the decus- 
sated facial tract is in the lower part of the pons, lying close to the still 
undecussated tract of the extremity of the opposite side. A lesion, 
therefore, which affects the lower part of one-half of the pons may pro- 
duce paralysis of the opposite side of the body and of the same side of 
the face — hemiplegia cruciata seu alternans, an important symptom of 
disease of the pons (compare Fig. 160). 

2. If the lesion affects a cortical center or a point in the pyramidal 
tract in the brain, the pons, oblongata, the spinal cord above the point 
of entrance of the particular tract into ganglia of the anterior horn (or 
analogous gray nuclei of the oblongata or of the pons), then, because 
the trophical influence of the cortical center from above ceases at that 
point, the affected tract degenerates just up to the corresponding cells 
of the anterior horn, while these and the peripheral nerves and the 
muscles do not degenerate. This degeneration of the pyramidal tract 
does not in itself cause any further clinical phenomena. On the other 
hand, if the lesion is in the anterior horn or downward from there in the 
motor tract, there is degeneration downward of the nerves and of the 
muscles supplied by the portion which is the seat of the lesion ; and 
this may be recognized cHnically from the signs of degenerative atrophy 
{relaxed paralysis, dimhiution in volume of vmscle, reaction of dege7ier- 
ation in electrical examination). 

3. Since the centers and tracts in the different sections in some in- 
stances lie wide apart and in others close together, a given extent of 
lesion, according to its location, will cause a paralysis widely different 
in its area : 

{a) A lesion of considerable extent located in the cortex, or in the 
corona radiata just under it, generally affects only the center for one- 
half of the countenance, or an arm, or a leg {inonoplegia, dissociated 
paralysis). There is also another important symptom which is char- 
acteristic of irritation of the cortex : spasms precede paralysis, and also 
linger after the paralysis disappears, in the area supplied by the affected 
portion of the cortex — " dissociated spasms!' These spasms may ex- 
tend to other parts of the body, but the part corresponding to the 
affected portion of the cortex is always the " primary seat of spasm." 

(b) If located in the internal capsule, then the lesion need not be so 
very large in order to ^^xodiWC^ paralysis of the whole of tJie opposite side 
of the body — hemiplegia. This points to the crus cerebri and also to 
the pons. 

{c) If the lesion is in the pons and oblongata, even though of slight 
extent, it affects fibers of the central tract as well as nuclei of the cere- 
bral nerves; it readily causes injury to centers that are very essential 
to life, the respiratory center^ vagus center for the heart, and death 
may soon follow ; if there is hemorrhage or softening, it often takes 
place immediately. 

4. It is of considerable diagnostic importance that at certain places 
some of the cranial nerves and the pyramidal tracts for the extremities 
lie in juxtaposition, and also that at the base of the crus cerebri the 
oculo-motorius passes near the pyramidal tract for the arm and leg of 



426 



SPECIAL DIAGNOSIS. 



the opposite side ; at the lower part of the pons the pyramidal tract 
again runs near the tract of the facial after its decussation (compare 
Fip- 




J/, spinal 



Fig. i6o. — Diagram of the motor tracts of the facial nerve and of the nerves of the extremities 

(Edinger). 
At A, B, C, are indicated supposed local diseases. A, lesion of the left side of the internal capsule, caus- 
ing right hemiplegia on the right side ; B, lesion of the left half of the pons, touches the pyramidal tract of 
the extremities of the right side and of the left facial, causing crossed paralyses ; C, shows the rare condition 
of uncrossed facial paralysis and paralysis of the extremities from lesion in the pons. 

A tumor at the base of the crus cerebri can therefore cause paralysis 
of the oculomotorius of the same side and of the arm and leg of the 



EXAMINATION OF THE NERVOUS SYSTEM. 427 

Opposite side (" crossed paralysis of the motor oculi and extremities " — 
" Weber's syndrome ") ; on the other hand, a lesion in the lower portion 
of the pons, as has already been explained, may cause paralysis of the 
facial of the same side and of the extremities of the opposite side 
(" crossed paralysis of the facial and extremities "). 

If the lesion is higher in the pons, above the decussation of the 
facial, it may cause paralysis of the facial and extremities of the opposite 
side; that is, a true hemiplegia (which is very rare) (compare Fig. 160). 

It has recently been discovered that paralysis of the oculo-motorius 
of one eye and tremor or disturbed co-ordination of the opposite arm 
point to the peduncle of the cerebellum {Beitedicfs sy7nptom-complex). 

5. A t7imor or an inflarmnatory affection at the base of the brain, 
according to its precise seat, injures the cerebral nerves passing there. 
If the focus is in the anterior cranial fossa, the olfactory is implicated ; 
if located in the middle cranial fossa, the opticus, the oculo-motorius, 
trochlearis, abducens, and sometimes also the olfactory, may become 
diseased. If in the posterior cranial fossa, then the trochlearis, abdu- 
cens, facial, acusticus, glosso-pharyngeus, vagus, accessorius, and hy- 
poglossus come into consideration.^ The disease may be bilateral. 
As has been partly explained above under 3, simultaneous injury of 
the cerebral peduncle, of the pons, and of the oblongata may implicate 
the pyramidal tracts : there is paralysis of the extremities. 

In diseases of the optic thalamus there have been observed homon- 
ymous hemianopsia, hemichorea, hemiathetosis, and one-sided tremor; 
but it is uncertain whether a part of these symptoms are not caused 
by the internal capsule, which lies close by. Foci in the corpus stri- 
atum cause the same difficulty. 

Foci in the cerebral peduncle, besides motor paralysis, not infre- 
quently cause sensible and vaso-motor paralysis of the opposite side. 
Crossed paralysis of the extremities and the oculo-motorius, more- 
over, may be caused not only by a tumor at the base of the cerebral 
peduncle, but also by a focus under the corpora quadrigemina ; in both 
cases paralysis of the third nerve is often complete — ptosis, dilatation 
of the pupil, and outward rotation of the eye by the adducens. 

If only one hemisphere participates in the disease, affections of the 
cerebellum often produce only indefinite or general symptoms. Phe- 
nomena of extreme diagnostic importance arise from the participation 
of the vermiform process, and by neighborhood symptoms from the 
corpora quadrigemina, pons, and oblongata or their nerves. Lesion of 
the vermiform process causes cerebellar ataxia, vertigo, and " riding- 
school gait" [cerebellar gait] ; the neighborhood symptoms are paraly- 
sis of the third and fourth nerves (corpora quadrigemina), and paralysis 
of the seventh nerve from the pons as well as from the floor of the fourth 
ventricle, paralysis of the sixth nerve, and trigeminal neuralgia. Among 
the general phenomena to be mentioned are the following : relatively 
early and well-marked choked optic disk, occipital headache, vomiting 
without ascertainable cause, convulsions, and compulsory position upon 
the side. 

I/Ocali^ation of Disease in the Spinal Cord. — In the 

^ Also see Fig. 159, which shows how the individual cerebral nerves run together at the 
base. 



428 



SPECIAL DIAGNOSIS. 



first place, particular significance attaches to the cervical and lumbar 
enlargements of the cord and the accumulation of nuclei in the an- 
terior horns for peripheral innervation of the extremities. It has been 
ascertained that within the enlargements lies the localization for indi- 
vidual parts of the muscle-system of the extremities, but our knowl- 
edge of the functions of the motor nuclei in the different sections of 
the dorsal cord is less exact. Much has also been learned, by com- 
parison of cases of disease, regarding the representation [mediation 
by nuclei] of conscious sensibility of the skin and of deep sensibility 
[sensibility in the deeper parts], which produce reflexes in the spinal 
cord. 

The simplest way to determine the seat of lesion in the different 
segments of the spinal cord is to keep in mind the height of entrance 
of the anterior posterior roots. These are given in Starr's table, which, 
with the author's permission, we copy from Edinger's work, already re- 
ferred to several times. The table also contains the localization of the 
reflexes. It is well to read what has been said above about reflexes in 
order to understand this table. 



Localization of 


the Function of Different Segments of the Spinal Cord. 


Segments. 


Muscles. 


Reflexes. 


Innervation of sensation 
of skin. 


r 


Sterno-mastoid. 


Inspiration on sudden 


Neck and occiput. 


Second and third 


Trapezius. 

Scaleni and muscles of 


pressure under the 
arch of the ribs. 




cervical. 


the neck. 








Diaphragm. 






' 


Diaphragm. 


Dilatation of pupils 


Neck, upper region of 




Supra- and infra-spina- 


after irritation of 


shoulder, outer side 




tus. 


the neck, fourth to 


of the arm. 


Fourth 


Deltoid. 


seventh cervical. 




cervical. j 


Biceps and coraco- 

brachialis. 
Supinator longus. 








Rhomboidei. 








Deltoid. 


Scapular reflex, fifth 


Posterior portion of 






cervical to first 


shoulder and arm. 






dorsal. 






Biceps and coraco- 


Tendon reflexes of 


Outer side of the upper 




brachialis. 


the respective mus- 
cles. 


and the forearm. 


Fifth 


Supinator longus et 




cervical. 


brevis. 
Pectoralis — clavicular 

portion. 
Serratus magnus. 
Rhomboidei. 
Brachialis anticus. 
Teres minor. 








Biceps. 


Reflexes from tendons 


Outer side of the fore- 




Brachialis anticus. 


of the extensors of 


arm. 




Pectoralis — clavicular 


the upper and the 






portion. 


forearm. 




Sixth 


Serratus magnus. 






cervical. 


Triceps. 








Extensors of the hand 


Tendons of the vi^rist, 


Back of hand, region 




and fingers. 


sixth to eighth cer- 
vical. 


of radialis. 




Pronators. 







EXAMINATION OF THE NERVOUS SYSTEM. 



429 



Segments. 


Muscles. 


Reflexes. 


Innervation of sensation 
of skin. 


r 


Long head of triceps. 


Blow upon the palm 






Extensors of hand and 


causes fingers to 






fingers. 


close. 




Seventh 
cervical. 


Flexors of hand. 
Pronators of hand. 




Radial region of hand. 


Pectoralis — costal por- 
tion. 








Subscapularis. 


Palmar reflex, seventh 
cervical to first dor- 




: 


Latissimus dorsi. 
Teres major. 


sal. 

1 

1 


Distribution of me- 
dian. 


Eighth 


Flexors of hand and 

fingers. 
Small muscles of the 






cervical. 


\ Pupil reflexes. 








hand. 








' 


Extensors of the thumb. 


J 




- Ulnar region. 


First 
dorsal. 


Small muscles of the 

hand. 
Ball of thumb and little 










finger. 








Second to twelfth 
dorsal. 


Muscles of back and 


Epigastrium, fourth to 


Skin of the chest, back. 


abdomen. 


seventh dorsal. 


abdomen, and upper 


Erectores spinge. 


Abdomen, seventh to 


gluteal region. 






eleventh dorsal. 






Ileo-psoas. 


Cremaster reflexes. 


Skin of region of 


First 
lumbar. 


Sartorius. 


first to third lumbar. 


p u b e s . Anterior 






side of scrotum. 




Abdominal muscles. 








Ileo-psoas. 


Tendon of patella, 
second to fourth 


Outer side of hip. 


Second 




lumbar. 




lumbar. 


Flexors of knee (Re- 
mak?). 








Quadriceps femoris. 






Third 


Quadriceps femoris. 




Anterior and inside 


lumbar. 


In-rotators of the thigh. 
Adductores femoris. 




of thigh. 


' 


Adductores femoris. 




Inner side of hip and 


Fourth 
lumbar. j 


Adductores femoris. 




leg to the ankle. 


Tibialis anticus. 


Gluteal reflexes, fourth 


Inner side of the 


Flexors of the knee 


to fifth lumbar. 


foot. 




(Ferrier?). 








Out-rotators of the hip. 




Back of hip, upper 




Flexors of knee (Fer- 




part of thigh, and 


Fifth 


rier?). 




outer part of the 


lumbar. 


Flexors of foot. 
Extensors of toes. 
Peronei. 




foot. 


First and second 


Flexors of foot and toes. 


Plantar reflexes. 


Back of upper part of 


sacrals. j 


Peronei. 




thigh, outer side of 


Small muscles of foot. 




leg and foot. 


Third to fifth f 
sacral. \ 


Muscles of the per- 


Tendo Achillis. 


Skin over sacrum, anus, 


ineum. 


Bladder and rectal 


perineum, genitals. 






centers. 





430 SPECIAL DIAGNOSIS. 

METHOD OF EXAMINATION. 

Examination of the Seat of Disease. 

From the physiological properties of the nervous system it follows, 
from what has hitherto been said, that when affected by disease there 
is little or nothing to be seen at the seat of the disease, while the 
symptoms are manifest at other portions of the body often quite distant 
from it. Besides, the brain and spinal cord are almost entirely removed 
from the possibility of being examined on account of their bony case- 
ments. Lastly, very often a local disease of the nervous system, al- 
though it causes pronounced phenomena, is locally very indistinct. 
For all these reasons the local examination of the nervous system in a 
number of its diseases is quite subordinate. Still, we place its con- 
sideration first because in a systematic examination it belongs there, 
and because the expression of our opinion cannot at all affect the value 
which it nevertheless in many respects possesses. 

The Skull. — The majority of the diseases of the brain and its 
coverings run their course without any manifest effect upon the skull ; 
indeed, there is no disease of that organ in which it may not more or 
less frequently happen that alterations in the skull were entirely want- 
ing. If there are such alterations in a portion of the cases they are 
secondary in their nature, dependent upon disease on the inner surface ; 
in other, more rare, cases the alterations of the skull are the cause of 
the disease of the brain. 

As methods of examination we mention inspection, palpation, and 
measiunng or tracing the shape of the cranium upon paper. 

The Size of the Cranium. — Generally this is determined by the 
circumference of the head over the glabella and the occipital protuber- 
ance, and by estimating the relation between the brain-case proper and 
the face. This latter can be measured simply by the eye. In the 
newly-born the circumference of the head is 39 to 40 cm. (according 
to others somewhat less). In the course of the first year it increases 
to about 45 cm., and from then to the beginning of the twelfth year to 
50 cm. ; in adults it amounts to about 55 cm. (in women it is generally 
somewhat less than in men. 

Marked enlargement of the cranium, macrocephalns (to 80 cm. and 
more in circumference), occurs with hydi^ocephalus if the fontanelles 
have not yet closed. Then the frontal bones particularly project ; the 
countenance is proportionally too small, the eyes are directed down- 
ward, the expression is often peculiarly staring ; the fontanelles are 
very large and remain open for a long time; the cranial bones are thin. 
Hydrocephalus which occurs later, when the skull has already closed, 
causes little or no enlargement of the head. 

Moreover, a somewhat considerable maa^ocephalns is peculiar to 
the rachitic skull, and is here dependent upon thickening of the cra- 
nial bones. But it is generally somewhat angular (caput quadratum). 
There is no notable recession of the bones of the face as in the former ; 
the bones give the impression of being dense, only the occipital bone 
is sometimes very thin, even as paper, sometimes upon pressure crack- 
ling like parchment (be careful !). Here, too, the fontanelles remain 



EXAMINATION OF THE NERVOUS SYSTEM. 43 1 

open abnormally long — sometimes into the third year. The distinction 
from hydrocephalus is made in the first place by an examination of the 
nervous system, which in this disease is almost always injuriously 
affected (as respects its psychic, intellectual, and motor functions), while 
in rachitis it is normal ; also the evidences of rachitis are to be sought 
at other points (the inferior maxilla, the thorax, the bones of the ex- 
tremities). Moreover, we may have a combination of hydrocephalus 
and rachitic thickening of the cranium. 

Abnormally small skull, microccpliahis, is naturally connected with 
abnormally small brain, thus necessarily with idiocy.^ The brain 
anomaly always seems to be the primary one. 

Form of the Skull. — Departures from the Typical Form. — Here 
belong dolichocephalus, brachycephalus, and other forms of head 
which are often met with without any pathological condition of the 
brain, but also in congenital malformation of the brain, as in idiots. 
Asymmetry of the skull likewise occurs with this condition, but also 
not infrequently with persons who are perfectly healthy and intelligent. 
We discover the asymmetry of the skull by viewing it from above or 
by tracing it upon paper, measuring the sagittal and the large trans- 
verse diameters of the cranium with the calipers, and making an outline 
with a strip of lead, as was described upon page 140 in the examination 
of the form of the thorax. 

Circumscribed projections and depressions have much greater path- 
ological significance, the latter, however, very frequently not with 
reference to disease of the brain, but as signs of a general disease. 
Projections occur in disease of the cranial walls and of the dura mater,^ 
and these are chiefly syphilitic gummata, carcinoma, and sarcoma. 
Sinkings-in, depressions, impressions, may be traumatic. If there is 
defect of the bony wall, the defect may feel like a fontanelle. Soft 
and slightly depressed [or depressible] round spots are sometimes 
present in carcinoma of the cranial vault. Very important, lastly, 
are scar-like, round depressions over which the scalp is adherent, and 
which often contain an actual scar : these occur as the result of healed 
syphilitic gummata or deep ulcerations. All these appearances, but 
especially the traumatic and syphilitic depressions, are of the greatest 
diagnostic importance. When the skull is thickly covered with hair 
they may be easily overlooked if we do not examine it with the 
greatest care by feeling all points. 

The anatomical relations between the skull and the brain, especially 
the convolutions and fissures on the surface of the latter, have great 
diagnostic significance. When there is a circumscribed depression or 
a prominence from tumor it is important to determine what part of the 
cerebral surface is pathologically affected. Again, it often is important 
when there are local brain-symptoms, especially if they point to the 
region of the cortex, to examine with the utmost care the part of the 
skull which overHes that portion of the brain to which the symptoms 
point. Recently the latter aspect of this subject has become of greatest 
interest, because brain-surgery has advanced to such a point that 

^ See below. 

2 The knowledge and significance of tumors of the cranium caused by meningocele and 
cephalocele are taught in works upon surgery. 



432 SPECIAL DIAGNOSIS, 

abscesses and circumscribed tumors can sometimes be operated upon. 
As these pathological conditions very often exist without a point of 
circumscribed tenderness upon the skull/ every direct sign of their 
location may be absent : their seat can only be determined indirectly 
from the immediate local symptoms. 

Some data are here introduced for determining upon the skull the 
most important regions of the surface of the brain.^ However, it 
must be borne in mind that the relation-space between the convo- 
lutions and furrows of the brain and the skull cap is not wholly 
constant, but rather varies within certain limits. For instance, the 
opening in the skull made by a trepan may miss the spot of the cortex 
sought for by as much as 5 cm. Hence, when in doubt, it is desirable 
to determine the location by applying a mild faradic current to the 
exposed cortex (Horsley), and then observe from which point the 
muscles of the arm, leg, or face of the opposite side are made to 
contract.^ 

Poirier, for convenience in determining locations, employs two lines, 
which he designates as the Rolando and Sylvian lines (see Fig. 161). 

id) The Rolando line is determined as follows : Mark with a blue 
pencil the upper angle of the zygomatic process of the temporal bone, 
then draw a line perpendicular to this process from just in front of the 
tragus — that is, between this and the posterior border of the temporo- 
maxillary joint. Upon this line, 7 cm. from the auditory meatus, is 
the lower end of the Rolando hne. In the sagittal suture measure 
one-half of the distance from the apex of the naso-frontal angle to the 
occipital protuberance, plus 2 cm. : this gives the upper end or junction 
of the Rolando line with the sagittal suture. 

{B) The Sylvian is a line drawn from the naso-frontal angle to ^ 
point I cm. above the lambda or 8 cm. above the external occipital 
protuberance. 

The relation of these lines to the central fissure (the fissure of 
Rolando) and to the fissure of Sylvius is seen in the illustration. It 
also shows the local relation of the most important regions of the 
cortex to Poirier's lines. The center for the lower extremity corre- 
sponds to the upper third ; ^ the center for the upper extremity, to the 
middle third ; the center for sight and tongue, to the lower third of the 
Rolando line. The motor speech-center lies somewhat below and 
anterior to the latter. The temporal lobe is found between the Sylvian 
line and the external auditory meatus, while the center for understand- 
ing of speech lies just under the Sylvian line. Abscesses of the tem- 
poral lobe generally lie somewhat deeper, nearer the ear. The sight- 
center of the cortex corresponds with the posterior end of the Sylvian 
line, near the middle line. 

When the external occipital protuberance is not distinct (adults), if the 
head is large, we may measure 18 cm., if small, 17 cm., from the naso- 

1 See below. 

2 In these we follow the statements of P. Poirier ( Topographic crnnioencephalique, Paris, 
1891), whose methods seem to us to be the best. 

3 For further information consult works upon Surgery. 

* In trephining at this point the surgeon must keep 2 cm. from the middle line in order 
to avoid the longitudinal sinus. The lateral sinus lies in the prolongation of the line of the 
zygomatic process toward the external occipital protuberance. 



EXAMINATION OF THE NERVOUS SYSTEM. 



433 



frontal angle on the sagittal suture : this gives the upper end of the 
Rolando line. 

In children the lower end of Rolando's line is found by measuring 
from the external auditory meatus to the sagittal suture : the point 
sought for lies about 15 cm. below the middle of this opening. Ac- 
cording to Poirier, the other data do not differ essentially in children. 



Rol a lido's line. 




Central sulcus. 



Fig. 161. — Topographical relations of the convolutions of the brain and of the cortical centers 

to the skull (after Poirier ).i 

MA, motor aphasia ; Z, tongue ; J^, n. facialis ; A, arm ; B, leg ; SC, sight-center ; IfC, hearing-center ; 
F^,F'^,F'^, first, second, third frontal convolutions; 'f^, T^, T^, first, second, third temporo-sphenoidal 
convolutions. 



Sensibility of the Cranium to Pressure. — This is ascertained by 
pressure with the finger or by gentle strokes with the tip of the finger 
or the percussion hammer. General sensibility to pressure occurs in 
nervousness, especially nervous pain in the head. We also sometimes 
meet with circumscribed sensibility to pressure in nervousness, likewise 
in hysteria ; but sometimes the latter corresponds with a circumscribed 
meningitis, as this may be caused chiefly by tumors, abscess of the 
brain, etc. If other signs of a disease of this character are present, its 
topical diagnosis may be aided by palpation and percussion ; by itself 
its results must be received with caution. 

Regarding the significance of dilatation of the veins of the skull, see 
page 224. 

Suppuration of the ear and nose (the latter seldom) plays an im- 
portant part as causes of meningitis and abscess of the brain. 

^ Combination of several figures taken from his book, which is cited below. 
28 



434 SPECIAL DIAGNOSIS. 

The Spinal Column. — Form. — The significance of the expressions 
scoliosis, kyphosis (lateral and posterior curvature of the spine), and 
kyphoscoliosis have already been referred to on page y^. Lordosis 
is an abnormal curvature forward. If these curvatures are obtuse- 
angled, none of them have a deleterious effect upon the spinal cord, or 
at least only exceptionally. Acute-angled kyphosis (^gibbous), as is 
usually caused by caries of the vertebrae, also by fracture of a vertebra, 
is of much greater importance, [causing] compression of the cord. It 
is to be remarked that in order to recognize slight lateral curvature it 
is desirable to mark the spines of the vertebrae, without moving the 
skin, with a blue crayon, and then to observe carefully the line that is 
thus formed. Any weakness or paralysis of the muscles of the spine 
on one or both sides may lead to secondary curvature of the spine, 
especially to scoliosis and lordosis.^ 

Diminished mobility of the spinal column, if it occurs with respect 
to the whole length in persons of mature years, is often not pathological. 
Complete general stiffness occurs also in arthritis deformans. If the 
stiffness is Hmited to a certain portion, while the rest of the vertebra 
have free motion, this is of pathological significance (almost always due 
to caries, and here we sometimes have stiffness without curvature of the 
spine). Forcible bending is then generally painful. The spinal column 
is abnormally mobile when there is weakness or paralysis of its extensor 
or flexor muscles in young persons. This is especially marked in juve- 
nile muscular atrophy, often in connection with habitual curvature. 

Sensitiveness of the vertebral column to pressure (especially of 
the spines of the vertebrae) may have a great variety of significance. It 
may occur in palpable diseases, etc., especially in caries, but also with 
tumors of the vertebrae, of the spinal meninges, spinal meningitis, also 
tabes ; but it may likewise occur with spinal irritation (particularly in 
the neck and between the shoulder-blades), as well as in hysteria, and 
here it may be excessive. We discover this sensibility by strong press- 
ure or by striking the spines of the vertebrae. Often, but by no means 
always, there is at the same time painful sensibility when a hot sponge 
or the cathode of the galvanic current is passed over it. 

Here, also, belongs the rigidity of the neck in meningitis, particu- 
larly basilar — an important sign of this disease ; also the rigidity of the 
whole spinal column in spinal meningitis. With the former, by the 
contraction of the cervical extensors of the head, the latter is often bent 
back to a marked degree — "boring into the pillow." Backward bend- 
ing of the vertebral column — opisthotonos — likewise occurs with attacks 
of tetanus ; with epileptic, and especially hysterical, convulsions. With 
the latter, as the " arc de cercle," there are sometimes incredible dis- 
tortions. 

The anatomical relation of the cord to the spinal column is as fol- 
lows : the cervical enlargement of the cord corresponds about with the 
third cervical or the first dorsal spine, the lumbar enlargement is about 
on the level with the ninth dorsal to the first lumbar vertebral spine ; 
the coitus terminalis begins at the first or second lumbar vertebra. 

Puncture of the Vertebral Canal ; Lumbar Puncture (Quincke). 
— This procedure was originally proposed for therapeutic purposes, but 

1 See still further regarding this under Function of the Muscles. 



EXAMINATION OF THE NERVOUS SYSTEM. 435 

it has been more valuable for diagnosis, as has been shown by experi- 
ence, than for treatment. 

Method of Procedure. — The puncture is made under strict aseptic 
precautions. The patient is placed upon the side with the legs fully 
drawn up or in a bent sitting posture. The puncture is made with an 
aspirating syringe whose needle has an internal measurement of about 
T mm. The needle is introduced in the space below the arch of the 
second, third, or fourth lumbar vertebra, either in the middle line 
(children) or near it ; in the adult puncturing close beside the spinal 
process, which projects into the space. The point of the needle is 
directed somewhat upward and, according to the age of the patient, 
pushed in from 2 cm. (maximum for children) to 6 mm. (maximum for 
adults). With a little practice it is easy to reach the subarachnoid space 
at the beginning of the cauda equina, when the cerebro-spinal fluid im- 
mediately flows out in drops or in a stream. The pressure and the 
amount of fluid vary within normal limits : sometimes also none at all 
escapes or the flow suddenly stops, probably in consequence of an ob- 
structing filament of the cauda. The liquid which flows out is pure 
liquor cerebro-spinalis — i. e. clear like water, precipitates no fibrin, con- 
tains only a little albumin, but abundant salts, particularly sodium 
chlorid. 

The use of this method for diagnostic purposes is greatly favored 
now-a-days by the well-known fact that the subarachnoidal spaces of 
the brain and spinal cord communicate with each other. For this rea- 
son the method has been employed for diagnosis of diseases of the 
interior of the skull even more than for diseases of the vertebral canal. 

The pressure under which the liquid flows out, as has been mentioned, 
normally varies very much, and therefore it cannot be safely turned to 
account in diagnosis of increased cerebral pressure, as was to have been 
expected, in such cases as hydrocephalus and tumors, where the press- 
ure has been found to be low. 

On the other hand, the quality of the liquid may be turned to account 
in a different direction : in meningitis it contains fibrin, though also 
sometimes in tumors. The percentage of albumin is higher in menin- 
gitis than normal or in tumors, while in the latter sugar has been 
demonstrated. But other admixtures have much more weight : blood 
in rupture of a cerebral hemorrhage into the lateral ventricle ; pus in 
all forms of purident meningitis — also micro-organisms : in meningitis 
tubercidosa, in by far the majority of cases, there are found within the 
precipitating flocks of fibrin or after careful deposition by the centri- 
fuge tubercle bacilli, which are demonstrable by the cover-glass method.^ 
In some cases tuberculosis could be proved by culture. Besides, in 
purident meningitis there occur strepto- and staphylococci, in epidemic 
cerebro-spinal meningitis.^ in rare instances the pneumococcus (Frankel), 
more frequently a diplococcus very like the gonococcus, the meningo- 
coccus intracellularis, which in cerebro-spinal meningitis has also been 
found in the purulent secretion from the nose. It is stained in the same 
manner as the gonococcus. 

The Peripheral Nerves and their Surroundings. — The nerves 
as the seat of disease come into consideration in all peripheral paralyses 

1 See p. 159,/-. 



43 6 SPECIAL DIAGNOSIS. 

and in neuralgias (also, among others, in reflex epilepsy). In order 
directly to examine a nerve-trunk an exact knowledge of its course is 
necessary, and also of the organs that surround it from which an inju- 
rious effect upon the nerve may proceed. 

By the examination of a nerve we learn its anatomical condition : 
any possible symmetrical thickening, with neuritis or perineuritis, un- 
equal thickening or tumors in the nerve, with neuro-fibroma, neuroma ; 
also any possible sensibility to pressure, as occurs with neuritis along 
the whole length of the diseased nerve, although this may be entirely 
absent. Finally, here belong the sensitive points in neuralgias.^ 

Moreover, a special examination must be made of certain points 
which, from any cause whatsoever, may easily be the starting-point 
of a disease of a peripheral nerve. These are — {a) those points where 
a nerve is especially exposed to traumatism because it lies near the 
surface of the body (especially if it at the same time lies over a bone). 
These situations essentially coincide, in part, with the electro-motor 
points to be mentioned later. Severe injuries, deep punctures, etc., of 
course, may destroy a nerve at any point. They are — {b) neighbor- 
hoods where a nerve may be exposed to injury from other organs. 
Here belongs compression by development of callus about the seat of 
fracture, especially of the bones of the extremities ; also compression 
and sometimes inflammatory irritation from glandular tumors (axilla, 
neck, etc.), aneurysm, hernia (crural nerve) ; lesion of the facial nerve 
caused by caries of the petrous portion [of the temporal bone], etc. 
Indeed, in case of lesion of a peripheral nerve, we are frequently able 
to find the seat of the disease in this sense, but in every single case it 
must be looked for. 

An extremely instructive case from the standpoint of diagnosis of 
the locus morbi was observed by Erb which w^as previously reported 
by the author. It was a case of ulnar neuritis resulting from exposure 
of the ulnar nerve from the fracture of the internal condyle of the 
humerus. The author has recently seen a similar case : both internal 
condyles of the humerus projected ; the sulcus ulnaris was broad and 
shallow. In the first case there was a unilateral, in the second a 
bilateral, ulnar neuritis resulting from frequent injury to the nerve 
at its exposed point. 

Examination of the Condition of the Mind. 

In this section, which touches upon a territory foreign to this work 
— the mental state — we must, of course, limit ourselves to a brief 
mention of what is necessary in making a medical examination. 

Mode of Examination. — An attentive observation of the 
behavior of the patient in bed, the expression of his countenance, his 
position, the reaction to external impressions, gives many disclosures 
regarding the faculty of perception and of his sensibility [or well-being]. 
By engaging the patient in conversation (Taking the Anamnesis, page 
19) we are able to discover more regarding these points and to judge 
of the intellectual activity — memory, imagination, possible delusions^ 
the ability to think logically. In testing the memory we take notice 

1 See p. 448. 



EXAMINATION OF THE NERVOUS SYSTEM. 437 

of the recollection of things that are long past, as well as of more 
recent events, or of what has taken place during the present illness. 
The test of the power of thought and of the imagination is made by 
more or less simple arithmetical problems and by questions which are 
suitable to the social position and the occupation of the patient. We 
observe the great difference which various degrees of education pro- 
duce in patients affected with the same disease, and we also take into 
consideration the age of the patient. We observe any possible diminu- 
tion or increase of action, both instinctive, as the taking of food or 
sexual indulgences, and of actions with conscious purpose. 

This expresses in general terms the course of the examination. To 
be sure, we shall very frequently be obliged, in order to recognize the 
first traces of a mental disorder, to take into consideration whether the 
patient lias changed m his nature or behavior. Thus, for example, if 
a person becomes suddenly forgetful, careless, and disorderly, this will 
have quite a different significance than if he had always from his youth 
been so. Of course in regard to these things we must chiefly rely 
upon the statements of his relatives. 

In what follows are given the explanation of the terms that have 
been adopted in the medical clinic, and the phenomena that accompany 
the several conditions : 

Disturbances of consciousness are designated, according to 
their severity, as — stupor, also somnolence (sleepiness, lethargy, from 
which the patient can easily be awakened) ; sopor, in which the patient 
can only be awakened by decided appeals to his senses ; coma, or 
complete loss of consciousness, in which the patient cannot be awak- 
ened in any way. The slightest degree of obtunded consciousness 
manifests itself in the scarcely noticeable trouble which it costs the 
patient to collect himself in order to answer a question or by his indif- 
ference with respect to being sick — a subjective sense of well-being. 
Further, there is an indication given by the sensibility to pain and the 
arbitrary or involuntary voidance of the stools and urine. In this 
respect the sensibility to pain often does not coincide with the other 
manifestations of consciousness. 

Disturbance of consciousjiess occurs — in acute infectious diseases, 
especially in typhoid fever} where the early manifestation of dulness 
has diagnostic value, but it -may accompany any infectious disease, and 
may pass into deep coma ; in acute poisoning of various kinds, espec- 
ially from narcotics ; as uremic, diabetic, carcinomatous coma ; as epi- 
leptic, apoplectic coma ; in meningitis ; in the most varying diseases of 
the brain, especially in tumors of the brain and its meninges. In the 
different forms of meningitis, however, consciousness may be retained 
for a remarkably long time. In tumors of the brain there is often for 
a long time a sHght obscuration. It occurs also in injuries and con- 
cussion of the cranium ; in large hemorrJiages ; in all chronic cachexias, 
and at the end of life, at any rate in the last moments. 

A patient who is in deep coma when he comes under the eye of 
the physician always causes great difficulty in diagnosis, the greatest 
when he can make no inquiry in regard to the patient. Systematic 
examination of the whole body is to be made — especially of the cra- 

^ See below. 



438 SPECIAL DIAGNOSIS. 

nium for wounds ; of the heart and blood-vessels ; for evidences of 
apoplexy, meningitis ; for signs of poisoning ; of the urine, which is 
to be drawn with the catheter (for sugar, reaction for chlorid of iron, 
for albumin, casts ; for certain poisons or as evidence of certain poisons, 
hemoglobin) ; lastly, of the stomach by evacuation (poisons). 

Special Phenomena of Obtunded Consciousness. — Delirium — 
that is, talk and gesticulations arising from delusions — may follow 
any disturbance of consciousness, but it occurs especially frequently 
with acute infectious diseases ; with severe cachexia, often as the 
end of life approaches ; finally, as delirium tremens seu potatorum 
in chronic alcoholic poisoning. The latter manifests itself by 
talkativeness, restlessness, rapid alternations between passion and 
great anxiety, fear, hallucinations of sight (small black animals, 
especially mice, etc.), loss of sensibility to pain and cold ; besides 
alcoholic trembling.^ 

The expression *' muttering delirium " is used to designate a low 
murmuring with profound disturbance of consciousness. It is always 
a serious indication of great weakness and occurs particularly with 
typhoid fever. 

Hysterical delirium forms a transition to the true psychoses, which 
cannot be treated here. 

Spasms, Vomiting. — See the respective chapters. 

Loss of consciousness, which quickly passes off, occurs as " syn- 
cope," " dizziness." This may be very benign, as in anemia and 
chlorosis, nervousness, great excitement, or severe pain. But it may 
have a serious significance — in elderly people as precursors of severe 
strokes of apoplexy ; in kidney-disease as a sign of uremia ; in disease 
of the heart and blood-vessels as angina pectoris, or as slight epileptic 
attacks (petit mal) ; lastly, it occurs in all possible chronic diseases of 
the brain, but especially in progressive paralysis. All of these condi- 
tions must be thought of when attacks of dizziness occur frequently in 
the same individual. 

Dizziness, Vertigo. — In many respects this is to be looked upon as 
a slight, temporary loss of consciousness or connected with it.^ But 
it only indicates a disturbance of the sense of equilibrium, and occurs 
as such most purely as a swimming of the eyes in diplopia^ from 
deception regarding the location of objects in space and regarding the 
level of the floor. It also occurs in affections of the ear {vertigo ab 
aure Ice so) ; in tumors of the brain, especially of the vermiform process 
of the cerebellum ; in multiple sclerosis ; with diseases of the stomach 
{vertigo a stomacho Iceso) ; in anemia ; in cerebral neurasthenia ; lastly, 
in chronic nicotin-poisoning. 

Pathological depreciation of the power of the mind to perform its 
functions is designated as imbecility. It occurs in all gradations from 
moderate diminution in the perceptive faculties to a complete animal 
condition. Congenital imbecility is designated idiocy ; when accom- 
panied with certain physical manifestations, as cretinism. As an ac- 
quired condition it occurs as dementia senilis, also in organic diseases 
of the brain, especially tumors, apoplexy, multiple sclerosis ; but also, 
as a temporary condition in convalescence from severe diseases, a 

1 See below. ^ See above. ^ See Eyes. 



EXAMhWATION OF THE NERVOUS SYSTEM. 439 

slight imbecility has been observed. Imbecility with delusions of 
greatness is a tolerably characteristic sign of progressive paralysis. 
Of disturbances of volitional impulses are to be mentioned — abulia 
(hypochondria, drunkenness, indulgence in morphia) ; loss of desire 
for food — anorexia; certain forms of pathological excesses; boiilimia 
(a morbidly great and unnatural appetite for eating all sorts of things), 
nymphomania, and satyriasis (abnormal sexual desires). 



DISTURBANCES OF SENSIBILITY. 

I. Sensitiveness to Peripheral Irritation. • 

The determination of the sensibility which a patient has for irrita- 
tions applied from the periphery (by the physician) is made difficult 
by the fact that the estimation of them must rest with the patient, who 
is the subject of the experiment. Subjective sensibility, especially to 
pain, without doubt varies with individuals : with ** torpid " persons 
and with the aged it is depreciated. Moreover, in a varying degree it 
is diminished with persons who are unconscious to the point of entire 
loss of sensation. Further, it will be influenced, when the irritation is 
slight, by the attentiveness of the person examined. The report of 
what is discovered in such examinations depends wholly upon the 
sincerity and good-will of the patient. We must always think of the 
possibility of simulation and concealment and the absence of favorable 
intention. 

Very little weight must be given to the statements of the patient as 
to his capacity to feel. The most brief examination is best, as securing 
the most exact answers, for we very often meet with erroneous concep- 
tions of the condition of the sensibility of the skin. 

Whenever we are testing the sensibility it is advisable to prevent the 
patient from seeing what ive are doing. If the disease is unilateral, it 
is desirable to make use of this circumstance to compare the diseased 
with the healthy side. As to how we are to guard against deception 
by simulation, see below. 

Finally, it is most emphatically recommended to employ the utmost 
similarity possible in the methods of making one's examinations, for only 
in this way is it possible constantly to sharpen his own judgment. More- 
over, every record of an examination should contain a statement of how 
the result was obtained. 

Passing over the higher senses, the sensibility to peripheral irritation 
is divided into {a) cutaneous sensibility, {p) the so-called deep sensibility. 

{a) Cutaneous Sensibility. — This, again, is divided into a number 
of qualities whose relation to each other and distinction one from the 
other are not yet entirely clear. We avoid any discussion of disputed 
points, and treat the qualities from the standpoint of clinical interest. 

I. The sense of touch, sensibility to contact, is tested by gently touch- 
ing the skin with the tip of the finger, the patient keeping his eyes 
closed, and whenever he feels the touch saying " Now " ; it is better if 
he will also say " On the hand," or on the given finger, etc. Thus we 
approximately test the sense of locality.^ And it is also recommended, 

^ See below. 



440 SPECIAL DIAGNOSIS. 

in order to shorten the examination, to test the latter immediately more 
exactly by having the patient designate with the tip of the finger the 
spot that is touched. If he is able to do this, then his sense of touch 
and of locality is normal ; if he cannot, there may be several reasons 
for his inability, as disturbance of the sense of touch and of locality, 
sometimes of the muscular sense, perception of position of the hand 
used in testing or pointing/ Then we must endeavor to separate the 
sense of touch from the sense of locality. 

In many cases of sHght disturbance the patient is able to feel the 
contact, but it is duller and different from what it is in normal places. 
Then we often obtain more exact information if we touch him with 
rough and soft materials and the hke. In other cases this procedure 
is unnecessary. 

2. The local sense, the power of localization, is tested by having the 
patient tell exactly where he has been touched. A healthy person 
can tell this with different degrees of accuracy according to the portion 
of the body which is touched. This about corresponds with the dis- 
tances on the body which the related sense of space has been found to 
give.^ 

Testing the sense of space (only required when from any reasons 
the sensibility must be tested with the greatest exactness) is best done 
with Sieveking's esthesiometer : by means of two sliding points we are 
able to measure the shortest distance at which the two points can be 
recognized as two separate objects. In health the minimal distance, on 
the average, is as follows : 

At the tip of the finger 2.5 to 5 mm. 

In the palm of the hand 8 to 12 " 

On the back of the hand 31 " 

The forearm and the leg about 40 " 

The back 40 to 70 " 

The upper arm and thigh about 75 " 

Analogous, although in its results not wholly corresponding to 
those of the above-mentioned method, is that of testing the sensation 
of movements (Leube) : it relates to the power to distinguish points 
and the shortest lines that can be drawn upon the skin. 

3. The sense of pressure residing in the skin is tested by the ability 
of the patient to determine the smallest differences between weights 
placed upon the skin. The hmb must lie firmly, so that the muscular 
sense •'^ is excluded. It is best to take blocks of wood of the same 
size (instead of metal), but made of different weight by being loaded 
with lead. The healthy person perceives differences of weight which 
are equal to about -^\.o ^ oi the absolute weight of the bodies em- 
ployed. Partial paralysis of the sense of pressure is frequently 
observed, especially in tabes. 

4. The sense of heat and cold is most quickly and simply tested 
by breathing and blowing upon the skin. Healthy persons distinguish 
the first from the second perfectly well. This method, however, is 
entirely unsatisfactory, because the finer disturbances of the sense of 

1 See below. ^ See p. 444. ^ gee this. 



EXAMINATION OF THE NERVOUS SYSTEM. 



441 



cold and heat are not revealed by it. Somewhat more exact is the test 
made by means of two test-tubes filled with water at different tempera- 
tures. We must select a difference of temperature which we ourselves 
distinctly recognize, as, for instance, by passing the hand over them. 
If with one of these methods we find a disturbance of one of the two 
temperature-senses, then we can more exactly determine the degree of 
this disturbance by employing temperatures which vary still more ; 
hence very low or very high (ice, hot water). At the same time we 
can thus determine the temperature at which cold- or heat-pain begins. 
A finer test of the sense of heat is made by the aid of the thermes- 
thesiometer. We recommend Nothnagel's — two cylindrical wooden 
vessels with metal bottoms, into each of which is dipped a thermom- 
eter to test the temperature of the water that is poured into them. 
In a very imperfect way we may make a substitute for this thermes- 
thesiometer by using two reagent-glasses half filled with water. In 
these are placed thermometers surrounded by pledgets of wadding. 
The temperature of the glasses is varied by dipping them into vessels 
of cold or hot water. The thermesthesiometer enables us to deter- 
mine exactly the fineness of the sensibility to heat and cold. The 
normal fineness of the sensibility to heat differs with the absolute 
height of the temperature which we select. Temperatures between 
27° C. and 33° C. are most delicately distinguished. Here the recog- 
nizable differences in health average 0.5° C, except over the legs, 
where the number may be somewhat larger, and on the back, where it 
is about 1° C. On the cheeks it is about 0.25*^ C. 

5. Sensibility to Pain.^ — We recommend to test exclusively by 
pinching a fold of skin between two fingers, because in this way, with 
some practice — it depends very much 
upon the size of the fold of skin that is 
taken, and it is recommended always to 
press the rounded portion of the skin 
— we can best attain some uniformity 
in regard to the amount of irritation em- 
ployed each time.^ With patients who 
are unconscious it very often happens that 
the sensibility to pain is the only quality 
of sensation that is accessible to examina- 
tion. When there is very decided uncon- 
sciousness we are made aware of it by the 
possible distortion of the countenance on 
account of pain or even a withdrawing of 
an extremity (not to be confounded with 
reflex of the skin).^ 

6. Electric Sensibility. — By the gal- 
vanic as well as the faradic current we can 
develop an objectively-visible as well as 
subjectively-painful sensibility of the skin. 
We confine ourselves to the description of Xh^ far ado-cutaneous sejisibility. 

^ Corresponding with the mode of procedure in making an examination, this is included 
here, although it properly belongs with Common Sensation (which see). 

2 Regarding pain caused by faradization, see below, ^ See this. 





Fig. 162. — Erb's electrode for testing 

the sensibility of the skin. 

a, tube of hard rubber; <5,free surface of 

the electrode. 



44 2 SFE CIA L DIA GNOSIS. 

It is best obtained by employing Erb's electrode for testing farado- 
cutaneous sensibility (made by Stohrer in Leipzig), which is a cable of 
insulated copper wires cut at right angles with its axis. We mount 
this electrode upon the cathode of the opening current of a Dubois's 
induction-coil (the other electrode may stand anywhere upon the 
body) and notice the distance of rotation when the point of the skin 
under examination becomes sensitive (minimum of sensation), and also 
where it stands when pain is produced. Then, besides, we are to test 
the galvanic resistance at each point tested,^ in order to have an approx- 
imate guide as to how strong a current, furnished by Dubois's appa- 
ratus, is exhausted by the resistance of the body (or of the skin) at the 
individual points ; hence, how much of it is lost each time in pro- 
ducing the irritation of the skin. The following table gives the aver- 
age figures of health as found by Erb, but we remark that the figures 
change according to the strength and construction of the induction 
apparatus employed, and also that the deviation of the needle (for 
testing the galvanic resistance) was attached to an old galvanometer 
without absolute divisions. For both of these reasons the relation of 
the figures to each other, rather than the absolute variation of the 
needle indicated by them, is of value : 

Deviation of the needle 
Points of resistance. Minimum. Pain, with 8 elements ; con- 

duction resistance 150. 

Cheeks 200-220 130 26° 

Neck 170-200 120 22° 

Upper arm 200 120 21° 

Forearm 190 1 15 18° 

Back of the hand 175 lio 15° 

Tip of the finger 125 90 2° 

Abdomen 190 120 20° 

Thigh 180 115 21° 

Lower leg 170 no 19° 

Back of the foot 175 no 10° 

Sole of the foot no 80 5° 

The method is further liable to error, regarding which we cannot 
speak here. 

Farado-cutaneous sensibility does not go entirely parallel with any 
other quality of sensibility. Most frequently, but not always, the 
sensations of pain produced by pinching, and the minimal sensations 
of pain produced by the faradic current, correspond with each other 
(this is especially the case in tabes). The method has not yet been 
sufficiently studied to be of independent diagnostic significance, and 
particularly to have a value for special diagnosis. Its application is 
chiefly to be recommended in unilateral slight disturbance of sensi- 
bility, from the possibility of making a comparison with the sound 
side, which cannot be quite certainly established when there is normal 
irritability of the skin. 

Regarding stereog?tosis, see page 446. 

Now, if by testing the sensibility we find it diminished, we speak 
of hypesthcsia, often incorrectly spoken of as anesthesia. If none is 
found — that is, if the strong or maximal irritation employed, which 

^ See under Electrical Examination for Motilitj. 



EXAMINATION OF THE NERVOUS SYSTEM. 443 

is always to be stated as accurately as possible, meets with no response 
— then we speak of loss of sensibility, or anesthesia. Heightened 
sensibility is hyperesthesia, or sensibility to variations of temperature 
and to pain. In many cases, especially in diseases of the peripheral 
nerves, the sensibility is equally altered in all its qualities ; in others, 
and especially in diseases of the spinal cord, in cerebral anesthesia, 
and not infrequently in hysteria, there exists a partial paralysis of 
sejtsibility. Of this the most frequent form is the diminution or absence 
of sensibility to pain — analgesia. 

When sensibility is slowly conducted (*' delayed sensibility ") it is 
recognized by requiring the patient, with his eyes closed, to call out 
" Now " the instant he has a sensation. Sometimes the pause can be 
measured by seconds (ten seconds and more). This phenomenon is 
most frequently observed with reference to pain, as in tabes and in 
peripheral paralysis. If we take hold of the patient and immediately 
pinch him, he will often call out " Now " twice, because he felt the 
touch, and then, later, the pinch : there is double sensibility. For this 
reason it is best to take up the skin first without pressing it, and then 
suddenly to pinch it. 

Gradual increase of sensibility to pain, when inflicted, so that just 
at the moment of being pinched it is inconsiderable, and later the 
pain increases markedly, appears by its phenomena and occurrence to 
be related to delayed communication of the pain. 

Perverse sensibility to changes of temperature (Striimpell) consists 
in cold being experienced as heat. According to our recent views of 
the complete opposition of the sensibility to heat and the sensibility 
to cold, this disturbance is not, as yet, explicable. Yet it has an 
analogy in those rare anomalies of sensibility where a gentle touch is 
felt as cold. 

After-sensibility (Naunyn) is a term used to describe a pain that 
when first inflicted immediately subsides, but for some time after 
returns, and, indeed, with increase of intensity. 

Polyesthesia (Fischer) : when one point of the esthesiometer is 
placed upon the surface, it feels as if there were two. 

Allochiria (Obersteiner) : when the right extremity is touched it 
is referred to the left, and vice versa, as in tabes, myelitis, hysteria, 
multiple sclerosis. 

Local Manifestations of Disturbed Sensibility. — Of course these 
are to be determined as accurately as possible. This is very easily 
done when the disturbance of sensibility is sharply bounded ; however, 
not infrequently the region of disturbed sensibility of the skin passes 
very gradually and indistinctly into the normal portion. Total anes- 
thesia is a curiosity. Unilateral anesthesia or hemianesthesia, not pass- 
ing beyond the middle line of the body, sometimes affecting the head, 
trunk, and extremities (including the mucous membrane) in a similar 
way, occurs with certain deposits in the internal capsule (in the pos- 
terior third of its posterior limb) and in hysteria. In the latter, and (it 
is said) also in the first case, there is simultaneously exact unilateral 
disturbance of all the higher senses. Para-anesthesia is anesthesia of 
both lower or both upper limbs. A zone of disturbed sensibility, a 
territory of any extent, may exist in all imaginable parts of the body. 



444 SPECIAL DIAGNOSIS. 

If it is small, it may easily be overlooked, unless the search for it is 
very carefully made : this is particularly apt to be the case in the ex- 
tremities. Here especially (but also on the trunk) we must carefully 
determine whether the anesthesia corresponds with the region of 
distribution of a cutaneous nerve or of a mixed nerve-trunk,^ or 
whether it is not confined to such a territory — that is, " diffuse " or 
" washed out." In the first case it would indicate an isolated disease 
of that particular nerve. Anesthesia (analgesia) affecting an extremity 
which is limited to the portion distributed about a joint (say, as far as 
the wrist or up as far as the elbow-joint, etc.) has been met with in 
certain functional neuroses, especially of the so-called hystero-trau- 
matic neuroses of the French. 

It may happen — indeed, it very frequently does — that an anesthetic 
territory does not really comprise the limits of a nerve of the extrem- 
ities, but the inner half of it is wanting. Thus in a radial paralysis 
there may be an anesthetic zone (easily overlooked) confined to a small 
part of the dorsal side of the forearm. This results, either because the 
nerve is not interrupted throughout its whole transverse section, or 
because we have that very puzzling phenomenon, the " vicarious " par- 
ticipation of a neighboring nerve. 

{b) Deep Sensibility. — This is divided into the less important 
categories of tlie dynamic sense, the sensation of spasm of the mus- 
cles, and the important so-called muscular sense, which is a generic 
name for a series of sensations. 

Dynamic sense is the capacity to recognize the weight or the differ- 
ence of weight between different bodies which one lifts. It may be 
exactly tested only with the upper extremities, and even here it is not 
wholly separable from the pressure-sense of the skin. Different 
weights are placed in a cloth sling pulled over the hand on to the 
wrist. A healthy person will recognize differences of one-fortieth 
[of one kilogram]. 

Sensation of spasm is the unpleasant sensation or pain which is 
experienced in very strong contraction of the muscles, as in cramp in 
the calf of the leg or strong faradic muscular stimulus with anesthesia 
of the skin. 

Muscular Sense. — Perception of Movement. — By this we understand 
the ability to recognize, with the eyes closed, the position a limb is in 
{conception of localizatioii) and the active and passive motions of a 
limb. It is due to the sensibility of the muscles, joints, and their liga- 
ments, by the feeling of varying tension of the skin in flexion and ex- 
tension of a joint, by the impressions of touch which come from por- 
tions of skin being in contact, as in the axilla and elsewhere. In a 
rude way we test the sensation of location and of motion in the arm 
(with the eyes closed) in persons with unilateral disease as follows : 
we place the diseased arm in different positions, and have the patient 
with the sound hand take hold of the wrist of the diseased arm. The 
same method may be employed in unilateral disease of the leg. 
Besides, it is well, when there is disease of the legs and bilateral affec- 
tion of the arms, to have the patient describe the positions in which 
they are placed or the passive motions of the joint that are made. We 

1 See p. 448. 



EXAMINATION OF THE NERVOUS SYSTEM. 445 

can also have the patient describe and represent numbers in the air 
with his hands. 

By perception of movement Goldschneider understands the percep- 
tion of passive movements only. He has studied this very carefully, 
and has particularly examined the physiological limits of its delicacy. 
For this purpose he has devised a *' movement measure," constructed 
on the principle that the force exerted by the passive motion makes 
an angle corresponding to a departure from a vertical line. In this 
way he has determined the physiological limits, which are expressed 
by an angle. Some of his findings are here given, which show ap- 
proximately the delicacy of this perception : 

Shoulder-joint 0.3°-o.6° 

Elbow-joint o.5°-o.8° 

Wrist-joint o.3°-o.6° 

Knee-joint o.5°-i.o° 

The first figure, for example, indicates that in healthy persons a move- 
ment at the shoulder-joint so slight that the humerus changes its 
relation to the extent of only o.3°-o.6° is distinctly perceived. It 
matters not what the point of departure is, so long as there is no dis- 
comfort, tension, etc. ; nor is the direction of the passive motion of 
importance. The test of the perception of passive motion is of course 
to be made with the eyes closed, so as to avoid as far as possible the 
sensibility excited in the skin by the seizure or motion of the Hmb by 
the examiner. The proximal part of the tested limb must sometimes 
be held firmly. The full account of these studies is given in Berliner 
klin. Wochenschrift, 1890, p. 322/. 

Romberg's Syn^ptoni. — The patient places his feet close together; 
as soon as he closes his eyes he begins to reel ; sometimes he may 
fall. The phenomenon is dependent upon anesthesia of the soles 
of the feet and disturbance of the muscular sense of the legs, which 
is no doubt increased by the existing ataxia,^ because in this con- 
dition the motions to correct the swinging are too violent ; this is 
especially characteristic of tabes dorsalis. [But something of this 
symptom may be present in health, owing to the lack of vision to cor- 
rect incipient lateral movements. This may be made clear by closing 
the eyes and then attempting to stand on one foot.] 

A finer test of the muscular sense may be made by placing before 
the patient a table with numbered squares like a chess-board, each 
square measuring about 10 cm. on a side, and having him point them 
out with the eyes open until he has them all in his head, and then with 
closed eyes to touch them with the hand, or, on the other hand, the 
patient moves his hand about the squares and names the fields as he 
comes to them. With the legs the same test may be made with cubes 
measuring 10 cm. on the side, placed one on top of another and then 
side by side. This test, however, requires a certain degree of intelli- 
gence on the part of the patient. 

Conception of space ('* finding one's position in space ") can be tested 
by placing substances of different thicknesses between his thumb and 
forefinger to ascertain the smallest perceptible differences of thickness. 

1 See this. 



446 SPECIAL DIAGNOSIS. 

In testing the conceptions of active motions we see that it is very 
much disturbed in paralysis, ataxia, and chorea.^ 

The Knowledge of Form (Stereognosis). — We recognize the form 
of bodies partly by the sensibility of the skin and partly by deep sensi- 
bility. The former is employed more for very small bodies (which can 
be grasped with the hand; here, indeed, the hand is the chief means), 
the latter more for large substances. Thus far, only the recognition 
of small bodies has been sought, especially in an exact way by Hoff- 
mann. 

Hoffmann's Test. — To make this test he selected a ball, half-ball, 
segment of a ball, a cone, a die, a three-cornered pyramid, a regular 
octahedron, and a dodecahedron — all of a size for the hand to grasp. 
He chiefly tested the hand of persons in health and sick people as 
regards their ability to recognize these bodies (to which popular names 
were given). 

Hoffmann and others have found that the recognition of small bodies 
was principally made by the skin and sense of space and of pressure of 
the skin, and to a less degree by the sense of motion in the joints and 
the power of determining the location in space. Also, that the active 
to-and-fro motion of the body in the hand for a different reason comes 
into consideration : if the active motion is wanting, then the stereognosis 
is hindered, but not abolished. 

At present the examination of stereognosis has no independent 
value ; testing the separate qualities of sensation is superior to it. 
According to our experience, the most important result of Hoff- 
mann's examination is the knowledge that the separate factors of 
stereognosis may. very perfectly act one for another when there are 
pathological disturbances. 

2. Sensible Phenomena of Irritation and Pain from Pressure upon 

Nerves. 

1. Paresthesia. — This occurs as a subjective sensation of touch, 
like fur, creeping of ants, creeping of insects, falling asleep ; also as a 
subjective sensation of pain, as a fine stinging or pricking, and also a 
severe pain ; lastly, as a subjective sensation of cold and heat or painful 
burning. 

The so-called feeling of constriction, which occurs most frequently 
upon the trunk in the region of the thoracic vertebrae, especially in tabes, 
but also in local disease of the spinal cord and its meninges, belongs 
here. Generally it is a sensation of tension, but it also occurs in all 
stages of transition to genuine neuralgic pains when it is deeply located.^ 

2. Spontaneous Pain. — Headache (Cephalalgia). — This, according 
to the manner of its occurrence as well as its significance, may be ex- 
tremely varied in its character. Its chief forms are — 

(a) Headache produced by palpable disease of the meninges in the 
different forms of meningitis — in all those diseases of the cranium and 
the brain which accompany meningitis. If the affection is circumscribed, 
the headache may likewise be so, and it then sometimes indicates the 
location of the disease ; but also often enough in this case it is not 
located. 

^ Regarding these, see below. ^ See below. 



EXAMINATION OF THE NERVOUS SYSTEM. 447 

Related with this are the nocturnal headaches of syphilis. 

(p) The headache of neurasthenia is quite various in its onset. 
Sometimes it appears as a painful pressure in the head, sometimes as 
extremely severe pain ; again, it is diffuse, then localized, especially at 
the crown of the head. There is the hysterical headache, not infre- 
quently circumscribed at the crown (clavus hystericus). 

ic) Migraine. This is generally an unilateral headache occurring 
with pauses of extremely varied duration, which is associated with dis- 
turbances of the stomach, scintillations,^ tinnitus aurium, dilatation or 
contraction of the pupil of the affected side, etc. The condition is idio- 
pathic or symptomatic, especially in tabes, tumors of the brain ; also 
sometimes in diseases of the nose, etc. 

(d) Neuralgia in the head.^ 

{/) Toxic headache occurs particularly in chronic poisoning with 
lead, mercury, alcohol, nicotin. Here also belongs the headache of 
uremia. 

(/) There is a headache which occurs in the beginning and during 
the course of acute infectious diseases, especially intense and long con- 
tinued in typhoid fever. 

(^) Anemic headache — headache with gastric dyspepsia ; abdominal 
diseases of all kinds, especially diseases of the female sexual organs. 

[h) The so-called habitual headache. Often there is an hereditary 
disposition to headache, which occurs with exertion, excitement, bodily 
disturbance, as catching cold, etc., and the disposition generally lasts 
during the greater part of one's life. 

Pain in the spine may concern the vertebrae, as in chronic rheuma- 
tism, arthritis deformans, caries; the spinal muscles, as in muscular 
rheumatism ; the spinal cord or its meninges, especially in meningitis 
and in tabes with tumors. But it occurs very frequently, and is espe- 
cially torturing, in neurasthenia and spinal irritation.^ 

Neuralgia. — This is generally a severe paroxysmal pain occurring 
in the region of one or more distinct nerves. It may be idiopathic or 
result from catching cold, but it may also be symptomatic, with the 
greatest variety of significance. The principal varieties of neuralgia are 
those produced by mechanical irritation (pressure of a tumor, aneurysm, 
periostitis, etc.) ; sequela of inflammation of the affected nerve ; neuralgia 
dependent upon infectious or toxic influences (malaria, syphilis, lead, 
mercury, nicotin, etc.), or accompanying constitutional diseases, as dia- 
betes, gout, phthisis. In every neuralgia we are to keep in mind the 
whole course of the affected nerve, and consider where and how it may 
be injured, and how such a local injury may directly or indirectly be 
discovered. 

Of special importance are the neuralgic, lightnmg-like , lancinating 
pains in the initial stage of tabes dorsaHs. They occur very much more 
frequently in the lower extremities and the trunk in the region of the 
intercostal nerves, and now-a-days are not infrequently confounded 
with rheumatism. Also in the beginning of multiple neuritis there are 
neuralgic pains, although generally of moderate intensity. 

We have previously mentioned the pain produced by pressure upon 

* See the Eye. '-^ See below. 

^ See also what was previously said regarding the vertebrae. 



448 



SPECIAL DIAGNOSIS. 



the head and upon the vertebrae. The peripheral nerve is sensitive to 
pressure in neuritis whenever this is accompanied by actual inflam- 
matory phenomena in the nerve or there is perineuritis. Very fre- 
quently there is especially pronounced tenderness of the nerve during 
an attack of neuralgia, but also often, although to a slighter degree, in 
the intervals. This tenderness is very great at certain points of the 
nerves, especially where the nerve can be pressed against the bone 
( Valleix's points) [points douloureux]. 

Tenderness and spontaneous pain in the joints, without anatomical 
changes and generally very changeable in severity, are characteristic 
of articular neuralgia. 

Distribution of the Sensory Cutaneous Nerves. 

It is recommended that the accompanying figures [Figs. 163 and 
164] be studied, in connection with which we will draw attention to a 
few points which seem to us to be especially important : 

I. The Nerves of the Head. — It is to be noticed that the nerve 
V^ also suppHes the conjunctiva and a portion of the mucous membrane 





Figs. 163 and 164.— Distribution of the cutaneous sensitive nerves upon the head (Seehg- 

miiller). 
oma, omi, N. occipit. maj. and minor (from the N. cervical, II. and III.) ; «;«. N. auricular, magn. (from 
N. cervic. III.) ; cs, N. cervical, superfic. (from N. cervic. III.) ; Vx, first branch of the fifth {so, N. supra- 
orbit. ; st, N., siipratrochl. ; it, N. infratrochl. ; e, N. ethmoid; /, N. lachrymal) ; Fg, second branch of the 
fifth (Jwz,'n. subcutan. maize seu zygomaticus) ; V^, third branch of fifth {at, N. auriculo-tempor. ; /J, N. 
buccinator. ; m, N. mental ); B, posterior branches of the cervical nerves. 

of the nose ; further, that when it is paralyzed we observe severe inflam- 
mation and ulceration of the eye (ophthalmia neuroparalytica), which 
until recently were regarded by most persons as arising from lesions, as 
by dust, etc., which were not warded off because they had not been 
seen. The author inclines to the old view that the disturbance of nutri- 
tion forms the starting-point of the trouble. Nerve V^ supplies the 
mucous membrane of the superior maxilla, a part of the gums and of 
the nose, the upper teeth, and the chorda [tympani] accompanies its 



EXAMINATION OF THE NERVOUS SYSTEM. 



449 



trunk : hence sometimes there is disturbance of the taste at the ante- 
rior portion [two-thirds] of the tongue. Nerve K supplies a portion 
of the tongue and the mucous membrane of the cheek and presides 
over the secretion of saHva. It contains motor fibers, of which the 



Fig. 165. 

^1. Vi, Vs, 1st, 2d, and 3d branches of the trigeminus ; C, cervical nerves ; B, brachial nerves ; ax, N. 
axillaris ; C7nd, N. cut. medialis ; cm, N. cut. medius ; c/, N. cut. lateralis ; IC, intercostal nerves; ra, rami 
anteriores ; ri, rami laterales ; L, lumbal nerves ; i/t, N. ileo-hypogastricus ; z'l, N. ilio-inguinalis ; /z, N. 
lumbo-inguinalis ; se, N. spermatic ext. ; c/, N. cutan. lateralis ; cr, N. cruralis; oSi, N. obturator; sc, Nn. 
scrotales ; dp, N. dorsalis penis ; c/>, N. cutan. post, (the last three sacral plexus). 

most important are those distributed to the muscles of mastication 
(masseter, temporalis, pterygoideus ext. et int.). 

3. Nerves of the Neck and Trunk. — These do not require any 
further explanation (compare Fig. 165). 

3. Nerves of the Shoulder, Arm, and Hand. — Here we are 
especially to note the smallness of the cutaneous filaments of the radial 
nerve that supply the dorsal side of the forearm. Anesthesia here may 

29 



45 o 



SPECIAL DIAGNOSIS. 



easily be overlooked. It is to be remarked also that the distribution 
of the cutaneous nerves to the fingers, and also to the hand, is subject 
to some changes, so that slight variations from the arrangement usually 
described ought not to lead to mistake. Lastly, very often on exam- 
ination of a peripheral paralysis it is found that the extension of the 
sensory disturbance lags behind that of the motor. The phenomenon 
is largely explained by a vicarious participation of neighboring cuta- 
neous nerves in a portion of the territory affected (notwithstanding the 





Vj? jtic- 

Fig. i66 a and b. — Distribution of the cutaneous nerves to the shoulder, arm, and hand 
(Henle). The region of the N. radial, is represented by the unbroken hatched lines, that of the 
N. ulnaris by the broken hatched lines. 

a, anterior, b, posterior surface; sc, Nn. suprascapular (plexus cervicalis) ; ax, chief branch of N. 
axillar; cps,cpi, Nn. cutanei post. sup. and inf. (from N. radialis) ; rn, terminal branches of N. radial ; c;«, 
cl, Nn. cutanei medius (also to the plexus) and lateralis (chiefly to the N. medianus) ; cp, N. cutan. palmar., 
N. rad. ; cmd, N. cutan. medialis ; vie, N. medianus ; u, N. ulnaris ; cpu, N. cutan. palm, ulnaris. 

many investigations regarding its existence, this idea of vicarious action 
has not yet been as clearly explained as is desirable). 

Paralysis of the brachial plexus at Erb's point ^ sometimes causes 
anesthesia in the region of the median nerve. Paralysis from compres- 

^ See Electrical Examination. 



EXAMINATION OF THE NERVOUS SYSTEM. 



451 



sion of the radial [musculo-spiral] at the point where it passes around 
[the humerus] causes sensory disturbance only at the hand/ because 
the posterior cutaneous nerves [internal, supplying the posterior and 
internal aspects of the arm as far as the elbow ; and external, arising- 
from the nerve on the outer border of the arm, is distributed to the 





Fig. 167 a and d. — -Distribution of the cutaneous nerves of the lower extremity (Henle). 

a, N. ileo-inguinal (plex. lumb.) ; H, N. lumbo-inguinal (to the geni to-crural, plex. lumbal.) ; se, N. 
spermat. ext. (to the genito-crural.) ; cp, N. cutan. post. (plex. ischiad.) ; cl, N. cutan. lateral, (plex. lumb.) ; 
cr, N. cruralis (plex. lumbal.) ; obt, N. obturator, (plex. lamb.) ; sa, N. saphen. (plex. lumbal.) ; cpe, N. 
commun. peron. (N. peron. tibial.) ; cti, N. commun. tibial. ; per', per", N. peronsei ram. superfic. et prof. ; 
cpm, N. cutan. post. med. (plex. ischiad.); cpp, N. cut. plant, propr. (N. tib.) ; plm.pll, N. plantar, medial, 
et lateral. (N. tib.). 

back of the forearm] are given off above the point of circumflexion. 
On the other hand, compression of the radial in the axilla (crutch- 
paralysis) often causes anesthesia of the forearm. 

4. Nerves of the I^ower ^Extremities. — (See the accompanying 
figure. Fig. 167 a and U). 

^ See Electrical Examination. 



452 SPECIAL DIAGNOSIS. 

DISTURBANCES OF MOTILITY. 

In this connection we consider not alone the disturbances of mus- 
cular action in the strict sense, but also the manifestations as respects 
tojuis and the nittrition of the muscles, the co-ordination of their 
actions, their electrical and mechanical irritability, and their reflex 
manifestations. 

I. Paralysis. 

By paralysis of a voluntary muscle we understand a condition in 
which, by the action of the will, it can only to a diminished extent, or 
cannot at all, be made to contract. If there is complete absence of 
voluntary contraction, we call the condition paralysis ; if the power 
of voluntary contraction is only diminished, it is called paresis. Paral- 
ysis is the result of some anomaly of the muscular nervous system or 
of its motor terminal apparatus. 

The loss of motion due to stiffness of the joint has nothing to do 
with paralysis. Such inability to move a joint is especially frequent 
in the extremities, and may lead the inexperienced into error. If there 
is simultaneous stiffness of the joint and paralysis, it maybe extremely 
difficult to determine the existence of the latter. Diminution of power 
of motion caused by pain has nothing to do with paralysis when there 
is only a want of self-control on the part of the patient. However, 
ver}^ severe pain may cause a local restriction of movement, which is, 
in fact, to be considered as a paralysis. 

Phenomena of Paralysis ; Methods of Examination. — 
Paralysis is recognized by the complete absence of the power of 
motion in the sense of action of the affected muscles, and, as regards 
the muscle itself, by the absence of contraction that can be seen or felt. 
An extensive paralysis, if it causes the muscles to be lax,^ produces a 
characteristic atonic behavior of the affected limb : if we raise it 
and then let go, it falls — an important symptom of loss of con- 
sciousness. As regards those muscles (and there are many such) 
whose failure does not in a very noticeable degree affect the motion of 
a limb because their actions are replaced by others, we recognize the 
paralysis by observing and feeling the muscles during active movements 
of the joint which would likely call them into action; among such 
belongs the supinator longus. Paresis is recognized by the diminu- 
tion of "native vigor" when resistance is called for; and also, sup- 
posing the joint to be free and an absence of tension on the part of 
the antagonizing muscles,^ by diminished freedom and rapidity of 
motion. Again, we sometimes resort to an attentive examination and 
careful feeling of the body of the muscle. On the other hand, we may 
be deceived by the statement of the patient that he has a feeling of 
great lassitude. 

For the examination of individual muscles, see page 492. 

Extent of Paralysis. — Paralysis of one-half of the body, with 
or without paralysis of the corresponding side of the face, is called 
hemiplegia. Paralysis of one side of the face, of an arm, a leg, is 
called monoplegia facialis, brachialis, sen crnralis. We also speak 

^ See below. ^ See Tonus of Muscles. 



EXAMINATION OF THE NERVOUS SYSTEM. 453 

of monoplegia brachio-facialis. Paraplegia infador is paralysis of 
both legs ; paraplegia superior, of both arms. Hemiplegia cruciata 
signifies paralysis of the arm of one side and the leg of the opposite 
side ; hemiplegia alternans, or likewise cruciata, paralysis of an ex- 
tremity of one side and of the facial or oculo-motorius of the other 
side. 

The extent of the paralysis is an extremely important aid in diag- 
nosis, as follows from the anatomical remarks made at the opening of 
this section. For anatomical diagnosis see further, below. 

2, Disturbance of the Nutrition Tone of the Muscles. 

Nutrition shows manifest differences that are very striking, and of 
the highest diagnostic importance. It is determined by the volume of 
the muscle and by its electrical behavior.^ 

More or less symmetrical diminution in the volume of the muscles 
of a portion of the limb is designated as diffuse atrophy ; when it affects 
a single muscle, as chnimscribed atrophy. A corresponding increase in 
the volume is called hypertrophy or pseudo-hypertrophy.^ The exist- 
ence of atrophy and its extent are determined by inspection and palpa- 
tion ; if possible also by measuring. Whenever one side alone is 
affected, we are always to compare it with the healthy side. Requir- 
ing the patient to make active motion, by which the muscle under 
examination is made to contract, or which causes contraction in the 
surrounding muscles, often makes the impression much clearer. We 
can easily combine testing the strength with the examination of the 
state of nutrition. 

The volume .of an extremity is measured with the tape-measure 
while the limb is extended at rest (both arms and both legs are to be 
in exactly the same position), and it is best done at certain points of 
election. 

We measure the upper arm at the point of its greatest circumfer- 
ence ; the forearm, 2 to 3 cm. below the lower margin of the inner 
condyle of the humerus ; the thigh, 1 5 cm. above the upper edge of 
the patella; the calf of the leg, at its greatest circumference. 

Thus in measuring the forearm and the thigh we must first fix the 
point where we are going to take the measure, and mark it with a blue 
pencil. 

Atrophy is divided into the following varieties, which are to be very 
sharply distinguished from each other : 

(a) Atrophy of Inactivity. — This consists of a diminution in the 
volume of the muscles, which is very slight, and which very slowly 
develops in the course of months of inactivity. Almost without ex- 
ception it supervenes in cases of paralysis, and also in any long- 
continued inaction of the muscles, as in surgical diseases which 
require the limb to be kept at rest. In this form of atrophy, as will 
be shown later, the electrical sensibility of the muscles is qualitatively 
unchanged. 

{b) Degenerative atrophy, with the so-called atrophic paralysis. 
This quickly leads to a high degree of atrophy of the affected muscles, 

^ See Electrical Examination. ^ See this below. 



454 SPECIAL DIAGNOSIS. 

and to a qualitative change in their electrical sensibility — the reaction 
of degeneration} This degenerative atrophy only occurs if the center 
which presides over the nutrition of the muscle, hence that portion of 
the gray matter of the anterior horn corresponding to the affected 
muscle, is disturbed or is separated from the muscle ; therefore in all 
primary and secondary diseases of the anterior horns, in local separa- 
tions or interruptions of the connection with the anterior roots or 
peripheral nerves, in peripheral neuritis. 

Here belong : poliomyelitis acuta, subacuta, chronica ; progressive 
muscular atrophy of spinal origin ; amyotrophic lateral sclerosis ; all 
processes within and of the spinal cord which destroy the gray sub- 
stance (tumors, hemorrhages, softening) ; compression of the anterior 
roots and the peripheral nerves ; traumatic complete separation ; severe 
contusion ; pressure-necrosis of these; and all forms of acute and slow 
degeneration or degenerative neuritis. 

Also, it will be understood that the motor nerves below the seat of 
the lesion, as far as to the muscle, atrophy.^ 

On the other hand, degenerative atrophy is wanting in all paralyses 
which are due to a disease of a motor tract above the anterior horn- 
ganglia — that is, in the pyramidal tract of the spinal cord, of the brain, 
and in the cortex of the brain. Therefore in these cases we only have 
the atrophy of inactivity. Moreover, degenerative atrophy is wanting 
m paralyses of myopathic origin^ and m functional paralyses. 

Nevertheless, degenerative atrophy in many diseases occurs in such 
a way as to cause great clinical difficulties : the rapid (developing 
within fourteen days) diminution in the volume of a muscle of course 
can only occur when the whole of the affected muscle or a large com- 
pact portion of it is suddenly, at an approximately definite time, com- 
pletely paralyzed by disease of the anterior horn or of a peripheral 
nerve (poliomyelitis acuta, section of a nerve, rheumatic facial paral- 
ysis, etc.). A disease developing slowly in the course of weeks and 
months causes slowly progressive atrophy, at first disseminated in the 
separate muscular fibers, only gradually becoming general. There are 
also difficulties in determining the reaction of degeneration in such 
slowly extending degenerative atrophy.^ We have the greatest dif- 
ficulty in making out degenerative atrophy when the disease is a dis- 
seminated one, in which bundles of muscular fiber that are still normal 
are distributed everywhere between diseased bundles.^ 

It is to be remarked that all cachexias cause general atrophy as 
well as atrophy of the muscles. But it is worthy of still further note 
that under the influence of a general atrophy the paralyzed mus- 
cles often become excessively atrophied, even when the atrophy is 
not a degenerative one. In cases of myelitis transversa and simple 
atrophy of inactivity of the legs, when there comes to be a general 
atrophy, we have often seen the legs become extremely atrophied, 
quite out of proportion to the volume of the arms. But there is 
no reaction of degeneration, and this fact furnishes diagnostic assist- 
ance. 

It is often extremely difficult for the beginner to form a conception 

^ See below. ^ See above, p. 419, and also under Electrical Examination. 

3 Regarding this see further, under Electrical Examination. 



EXAMINATION OF THE NERVOUS SYSTEM. 



455 




of the behavior of the anterior gray columns when there is disease of 
a transverse section of the spinal cord, and to answer the question in 
connection with it, What sort of paralysis will result from such disease ? 
For this reason two examples are pre- 
sented : 

In a severe contusion of the promi- 
nence of the neck (fracture of a cervical 
vertebra, for instance) it may happen 
that the whole section of the anterior 
gray columns, which innervates the 
arms, is disturbed, and that simultane- 
ously the pyramidal-tract fibers for the 
muscles of both legs are unbroken (at 
H in the figure) : there follows a degen- 
erative atrophic paralysis of the arms 
and a non-atrophic, " simple " (spastic^) 
paralysis of the legs. The pyramidal- 
tract fibers of the latter degenerate as 
far as the lumbar portions of the cord 
(as far as Z), but the degeneration stops 
here : the anterior-horn ganglia remain 
normal, and hence the peripheral nerve 
and muscle also. 

A myelitis transversa of the dorsal 
portion of the cord interrupts the pyra- 
midal tracts to the legs ; these become 
simply (spastically) paralyzed ; a mye- 
litis transversa of the lumbar portion 
of the cord disturbs the anterior-horn 
ganglia of the legs : these are affected 
with atrophic paralysis. 

{c) Primary Myopathic Atrophy. — 
This is a disease of the muscle, the 
nervous system being intact. It mani- 
fests itself by the fact that in this disease 
the muscle gives less response, corre- 
sponding to a simple diminution in its 
volume ; or, if it becomes completely 

shrunken, there is complete paralysis ; and further, by the fact that 
the electrical examination, as a rule, does not exhibit any trace of 
the reaction of degeneration. This kind of atrophic paralysis occurs 
in two quite dissimilar forms : 

1. In muscular dystrophia (Erb), the myopathic form of progressive 
muscular atrophy (here often combined with hypertrophy or pseudo- 
hypertrophy).^ 

2. In severe chronic diseases of the joints. 

The parallelism between atrophy and paralysis mentioned above is, 
moreover, generally present also in degenerative-atrophic paralyses, 
provided they develop gradually ; that is, in subacute and chronic 
cases. A distinct disunion of atrophy and paralysis occurs only in 




Fig. i68. — Schema of the innerva- 
tion of the muscles (partly from Edin- 
ger). The radiation of the Py-tracts 
varies at different portions of the cortex 

(see p. 417). 



See under Tonus. 



2 See next page. 



456 SPECIAL DIAGNOSIS. 

acute degenerative-atrophic paralysis (poliomyelitis acuta, injury, etc. 
of the nerve, acute degenerative neuritis) ; here the paralysis develops 
more or less rapidly, but atrophy only becomes manifest in the course 
of weeks. 

Charcot has recently discovered, in certain hystero-traumatic paraly- 
ses, a functional paralysis with more marked atrophy, but without the 
reaction of degeneration.^ But the atrophy here is not so decided as 
degenerative atrophy, being rather between this and the atrophy of 
inactivity. 

In very exceptional cases, when there is disease of the cerebrum, 
particularly of its cortex, there has been found a considerable muscular 
atrophy, which appears early, sometimes even before the occurrence of 
paralysis, without the reaction of degeneration. In individual cases of 
this character contractures were completely wanting and tendon-reflex 
was not increased. 

Genuine hypertrophy of muscles occurs in Tliomsen's disease [gen- 
eral myopathic spasm] ; also sometimes in individual muscles, especially 
the gastrocnemius muscle in dystrophia musculorum ; here also belongs 
the muscular hypertrophy which develops in the sound leg when one 
is paralyzed (as in long-standing infantile paralysis). Genuine hyper- 
trophy is recognized by the increased volume, great hardness, and 
especially by the increased vigor of the muscle. 

Pseudo-hypertrophy , on the other hand, shows increased volume, 
but diminished power. This occurs in dystrophia musculorum much 
oftener than genuine hypertrophy, but it may be developed from the 
latter. 

Tonus of Paralysed Muscles {Active Spasm; Rigidity of 
Muscles^. — An increased tonus of the muscles that are paralyzed 
(rigidity, active spasm) is a characteristic, though sometimes absent, 
sign of those paralyses which are caused by diseases in the central 
neuron. This tonus may be so slight that the examiner will only 
notice it as a shghtly increased resistance during passive motion. But 
it may also be so strong that even when perfectly at rest a muscle is as 
hard as a board, and that motion of a joint in which the muscle would 
be extended (that is, in which the muscle would act as an antagonizer) 
is entirely impossible. Thus spasm of the quadriceps prevents bending 
of the knee, not only passive, but also active bending, which, probably, 
if the flexing muscles were intact or were only paretic, would take place 
{spastic pseudo-paralysis). Patients also, even in slight degrees of 
rigidity, experience great difficulty in making active motions. That 
these spasms are not due to permanent anatomical changes in the mus- 
cles, only to muscular contraction, is proved by the fact that they are 
sometimes subject to striking change. If the paralyzed muscles are 
spastic to a high degree, often for a long time there does not develop 
any atrophy of inactivity. 

Paralyses due to affections of the cortex of the brain usually mani- 
fest themselves by very early spasms. In hysteria also very decidedly 
active spasms occur. 

Regarding increased tendon reflex as an attendant phenomenon of 
spasms, see page 359. 

1 Hereafter the abbreviation R. D. will frequently be used for " reaction of degeneration." 



EXAMINATION OF THE NERVOUS SYSTEM. 457 

Atonic Paralysis. — This is characterized by diminution or loss of 
muscular tonus, in consequence of which there is abnormal passive 
mobility of the joints. This laxness is present in recent paralyses, in 
which the atrophic, acutely degenerative condition has not yet devel- 
oped (" atonic atrophic paralysis "). It is also found in cases of chronic 
and long-standing degenerative paralysis (see also under Contractures). 
Cerebral paralyses, as hemiplegia, in rare cases may also manifest 
decided atony. In tabes ^ there is a tolerably marked laxness of the 
muscle, without paralysis. 

Contractures. — In long-continued paralyses, both degenerative and 
simple, there develops in the paralyzed limbs a constant anatomical 
shortening of individual muscles, and, indeed, just the muscles that 
are chiefly spastic often shorten in spastic paralysis, but not always. 
On the other hand, in degenerative paralysis it is more the antago- 
nizers of the paralyzed muscles or those of the paralyzed muscles that 
are strongest. Thus from the moment of paralysis the prevailing 
position, the posture of the affected limb, gives the first indication of 
the development of contracture. These contractures do not change. 
The motions of the limb that oppose the contracture and the stretch- 
ing of the affected muscles caused by this motion are very painful. 

3. The Reflexes. 

I. Skin Reflexes. — By this we understand the quickly passing 
contractions of the muscles which are caused by an irritation applied 
to the skin. The stimulation of the skin usually recommended is tick- 
ling or stroking it with the blunt end of a pencil or the handle of the 
percussion hammer. It is well from the beginning to aim at a certain 
symmetry in the methods we employ ; only in certain cases, especially 
if there is diminution of the reflex, we may endeavor to call it forth by 
pricking with a needle or touching it with a piece of ice, etc. The skin 
reflexes about to be mentioned in detail are, even in health, very differ- 
ent in different individuals (the cremaster reflex relatively varies least), 
but upon both halves of the body they are always alike. Therefore, 
where there are unilateral anomalies of it the most certain results of 
trial of the skin reflex are obtained by a comparison with the sound 
side. If we have like results upon both sides of the body, then it has 
only a doubtful diagnostic value. 

We are not to confound with skin reflexes those motions that are 
voluntarily made. With some practice they are readily distinguished. 

In the face and the upper extremities the skin reflexes are of no 
importance ; on the other hand, the three reflexes upon the legs and 
abdomen are of especial diagnostic significance: 

(a) The reflex of the sole of the foot. — This is produced by irrita- 
ting the skin of the sole of the foot, and in health consists either in 
a dorsal flexion of the toes or of the whole foot, or even in motion of 
the hip-joint and knee. Pathologically, the reflex may be absent 
(weakened on one side and increased upon the other). It may be 
increased with reference to the amount of the contraction, with refer- 
ence to its extent, as in simultaneous contraction of the other leg, 

^ See also p. 461. 



458 SPECIAL DIAGNOSIS. 

motion of the pelvis or of the whole body for instance, as shorter opis- 
thotonos ; or it may occur slowly, or only after repeated and continued 
application or summation of a strong irritation. It would be influenced 
in its form by the tonus of the muscles of the legs : in spasm of the 
extensor, for instance, often, instead of a single motion of flexion there 
occurs repeated trembling. 

(^) TJic crcmaster reflex in men consists of a prompt upward motion 
of the testicle from the contraction of the cremaster which follows irri- 
tation upon the inner surface of the thigh. It is not to be confounded 
with the indolent contraction of the tunica dartos of the scrotum, 
which follows somewhat later. Sometimes the cremaster reflex is 
extended to the muscles of the abdomen, causing the backward draw- 
ing-in of the abdomen. 

(r) Abdomhial reflexes. — If the hand is quickly passed over the 
skin of the abdomen, there follows a contraction of. the transverse 
abdominal muscles on the irritated side, or even on both sides. If the 
reflex is strong, the retraction of the abdomen is unmistakable. When 
the reflex is weak we sometimes only notice a slight displacement of 
the navel toward the side irritated. We distinguish three abdominal 
reflexes on each side above, within, and below the navel depression. 

Fig. 169 explains the mechanism of the skin reflexes : the sensible 
irritation proceeding from the skin is conveyed by the motor fibers to 
the anterior horn ; but the anterior horn itself is influenced by the 
reflex retarding fibers which pass in the pyramidal tract. It is clear 
that the skin reflex must be lost by an interruption of the reflex arc 
at any point, or by unsusceptibility of the skin, or by myopathic 
paralysis — that it must be increased with any increased excitability of 
the anterior horn or removal of the restraining reflex from the brain ; 
also in hyperesthesia of the skin. Recently an increase of the abdom- 
inal reflex upon one side has been observed in intercostal neuralgia 
(Seeligmiiller). 

We have not mentioned a number of other skin reflexes, since they 
are not important. For pupillary reflex^ the reflex closure of the lids, 
see under Examination of the Eye. 

Of the reflexes of the mucous membrane, the choking reflex when 
the mucous membrane of the pharynx is tickled has diagnostic sig- 
nificance : its absence is a frequent occurrence in hysteria (anesthesia 
of the mucous membrane), also in bulbar paralysis (nuclear paralysis). 

Of very much greater diagnostic importance are the — 

2. Tendon Reflexes {Periosteal, Fascial, Reflex). — These reflexes 
are likewise short contractions. They are produced by taps upon 
the tendons of muscles, upon the bones and fascia, also by sudden 
tension of a tendon by a quick passive movement, in which, how- 
ever, the muscle itself is also stretched. Both the short movement of 
the limb and the momentary hardening of the muscle may be made an 
object of examination. In order to develop the tendon reflex it is 
necessary to have the limb perfectly relaxed, and it is well also to 
divert the attention of the patient. 

Whenever it is possible a comparison is to be made between the 
right and left limbs, but even where this cannot be done, as when the 
disturbance is bilateral or the two sides are disturbed in a similar 



EXAMINATION OF THE NERVOUS SYSTEM. 



459 



way, the greatest importance can be attached to the result of the test, 
because here the individual variations are not prominent, as they are 
in the reflexes of the skin ; hence the tendon reflexes are much more 
important aids in diagnosis than the skin reflexes. 

Tendon and skin reflexes may be confounded. In a doubtful case 
this can be avoided by comparing irritation of the skin alone at the 
given points by means of pinching, pricking a fold of skin, or by direct 




Fig. 169.— Diagram of the course of the cutaneous and tendon reflexes. 

H, skin ; M, muscle ; V, anterior horn ; Hi, posterior horn ; ^, the tract of the tendon reflexes ; h, the 

tract of the cutaneous reflexes. 



mechanical muscular irritation ■} lastly, as in the skin reflexes, by 
having the patient take part in the examination by making voluntary 
contractions : these take place later, and hence can only deceive the 
inexperienced. We may be very easily misled into supposing that 
there is an absence of tendon reflex if the muscles under examination 
are not perfectly relaxed. 

We enumerate the tendon reflexes according to their importance : 
(a) Patellar reflex (Erb ; knee-phenomenon, Westphal) consists in a 
contraction of the quadriceps. It is caused by striking with a percus- 
sion hammer, with the tips of the semi-flexed fingers, or with the rim 
of the ear-plate of a stethoscope, upon the patellar tendon. Often we 
must carefully seek the most susceptible point. 

Sometimes we may first make the test with the leg covered, but if 
the result is in any way doubtful, then the knee must be uncovered. 
Whenever a very exact examination is to be made, the latter must 
always be done. In order to get the muscles completely relaxed, we 
must select certain positions : a favorable position is to have the limb 
extended at rest, with the feet resting upon the floor ; another position 
is with the leg crossed over the other in the sitting position ; a third 
is to have the patient sit upon a table with the legs hanging down ; 

^ See below, Biceps-tendon Reflex. 



460 SPECIAL DIAGNOSIS. 

with the patient in bed we pass the hand under [the thigh just above] 
the knee and gently hft it. As a means of inducing patients to 
relax the limb they are to be diverted by conversation, or they may 
be directed to close the fist as tightly as possible, or sometimes we 
may have them grasp the left hand of the examiner or press the hand 
of some one else. 

Not only active contraction, but possibly also increased tortus of 
the quadriceps, disturbs the exhibition of the reflex. Even a patho- 
logically increased patellar reflex may thus be hindered by spasm, 
which must be carefully guarded against. Hence, so far as pos- 
sible, we must prevent any active spasm by the position (particularly 
by a cautious passive motion) of the knee-joint. It may also be inter- 
fered with by deformity and stiffness of the joint. 

With very rare exceptions the patellar tendon reflex is always 
present in health, and both sides are equally strong. 

The author cannot forbear saying that he regards as impracticable 
the designation '* Westphal's sign " for the absence of patellar reflex — 
notwithstanding his very high regard for this meritorious investigator, 
who is deserving of the honor — because this designation could easily 
be confounded with the opposite (as, that Westphal's sign meant 
patellar reflex). 

{b^ Tendo-Achillis Reflex and Foot-phenomenon. — Striking upon the 
tendo Achillis, and often only on a very limited portion of it, in health 
generally causes a reflex contraction of the gastrocnemius (and soleus) 
with slight plantar flexion of the foot. In doing it, it is best to lift 
the foot by taking the malleoli with the left hand (the foot of course 
being bare). 

By foot-phenomenojt we designate the contraction of the same 
muscles if there is a continuous contraction, a passive dorsal flexion 
of the foot, often best excited by a quick passive motion (stretching 
the tendons, also the muscles) ; a reaction then takes place in a series 
of rhythmical contractions of the plantar flexors or a long series of 
contractions — foot clonus, foot-phenomena, dorsal clonus. This latter 
phenomenon is not really a pure tendon-reflex ; rather in part it is 
dependent upon direct irritation of the muscles as a result of stretch- 
ing. But it has exactly the same diagnostic significance as increased 
tendon-reflex, for it does not at all occur in health, or, at most, only 
temporarily, as when one is very tired. 

{c) Tendon Reflex of the Upper Extremities. — Here they do not have 
the same diagnostic importance [as those under (a) and (b)\, particu- 
larly because they are very often absent in health. Striking the flexor 
tendons at the wrist-joint, the biceps at the bend of the elbow, the 
triceps tendon close above the olecranon, generally causes a sHght 
reflex contraction ; in the two latter we must be careful not to strike 
the muscle itself^ 

(^) Periosteal and facial reflexes are elicited by striking the latter 
and the bones — the tibia: patellar reflex; bones at the wrist-joint: 
biceps, even pectoralis reflex. We not infrequently observe them in 
health, but very particularly when there is increased tendon reflex. 
Not wholly unimportant also are the bone reflexes which are manifest 

^ See Mechanical Irritation. 



EXAMINATION OF THE NERVOUS SYSTEM. 46 1 

in the muscles of the face from blows upon the chin and upon the 
nose ; they are absent in bulbar paralysis, and are present in paralysis 
of the facial tract above the bulb. 

The mechanism of the tendojt reflex is made clear by Fig. 169, page 
459. We see that for its production it is necessary to preserve the 
integrity of the reflex arc : [a) tendons ; (8) sensitive (that is, centrip- 
etal) nerve; (c) posterior root; (d) anterior horn; {c) motor nerve; 
lastly (/) muscle. But we take note of the influence upon these of 
restraining fibres in the pyramidal tract, which may be cut off, and also 
may possibly be temporarily irritated. Interruption of the pyramidal 
tract, which is manifest by its secondary degeneration as far as the 
anterior horn, or cutting off of the pyramidal tract by primary degen- 
eration, causes increase, therefore, of tendon reflex, as in cerebral 
paralyses, spinal paralyses from disease of the pyramidal tract, in 
myelitis transversa, amyotrophic lateral sclerosis, spastic spinal paral- 
ysis ; but also increased irritability of the spinal cord itself, as in 
strychnia-poisonhig, tetanus, lyssa, neuroses, and particularly some- 
times in hysteria. On the other hand, the tendon reflexes are dimin- 
ished or are lost in disease of the anterior horns, of the peripheral 
nerves, of the posterior roots or their connection with the anterior 
horns (^poliomyelitis, spinal progressive miisctdar atrophy; any disease 
of the peripheral nerves ; tabes dorsalis — here diagnostically very im- 
portant; myelitis, tumors, hemorrhages, if in certain locations — that 
is, if they disturb the gray substance for the arm or leg). 

It follows from what precedes that the increase, and also in many 
respects the diminution, of the tendon reflexes goes parallel with in- 
creased or diminished tonus of the muscles. And, in fact, tonus seems 
to be genetically related to tendon reflexes. In this sense it is also of 
interest that the predominant reflexes of the arm are the flexors, of 
the leg the extensor of the knee, the plantar flexor tendo Achillis, reflex 
of the foot, and that exactly corresponding with a recent spastic paral- 
ysis of the arm we are apt to have flexor spasm of the arm and 
extensor spasm with paralysis of the leg at the knee and ankle. 

Westphal's view that the '' tendon reflexes " are not reflexes, but 
that they are always, when ehcited by the prescribed methods of 
testing, due to the direct irritation of the muscles by stretching 
and concussion, is to be regarded, especially as respects patellar 
reflex, as definitely refuted. Nevertheless, we must still agree that 
the ordinary method of examination for the foot-phenomenon in this 
respect is not free from objection (as has been urged by others also, 
as by Jendrassik) : the brusque dorsal flexion of the foot must neces- 
sarily stretch the gastrocnemius — here it may be due to the effect of 
stretching of the muscle added to that of the tendon. 

Mixture of tendon reflex and direct muscular irritation from stretch- 
ing the muscle probably also occurs in executing " brusque passive 
motion " of the limb (very quickly bending it and extending the knee- 
joint, etc.), which is very strongly to be recommended for determining 
a slight degree of increased tonus of the muscles. 



462 SPECIAL DIAGNOSIS. 

4. Electrical Examination of the Nerves and fluscles.^ 

REGARDING THE PHYSICS, AND THE INSTRUMENTS EMPLOYED. 

The electrical examination of the motor nerves and of the muscles 
consists in an electrical irritation of these organs at points where they 
are situated subjacent to the skin. 

For the electrical examination we employ the faradic induction 
current of the secondary spiral of a Dubois-Reymond sliding appa- 
ratus and the constant current of a galvanic battery. We cannot give 
a full description of these instruments here. They are fully described 
in works upon Physics. We speak only of what is of particular impor- 
tance for electrical diagnosis. 

It is especially necessary that the [faradic] apparatus should be so 
made as to enable the user to graduate tJie strcngtli of the current in any 
way that may be required. In the faradic battery this is done by chang- 
ing the position of the outer or secondary coil Avith reference to the 
inner or primary one : the greater the distance between the coils the 
weaker the secondary current becomes, assuming always that the 
strength of the primary current, usually supplied by a chromic acid 
element, remains constant. If both coils are pushed completely one 
over the other the greatest possible strength of the secondary current 
is obtained. In this position we say that the distance of the spirals is 
equal to o. The further the outer spiral is removed from this point the 
weaker the secondar}^ current becomes. A scale is fixed to the appa- 
ratus for a measure of the degree of weakening or, in other words, for 
the strength of the secondary current. This scale indicates in centi- 
meters and millimeters the displacement of the outer from the inner 
coil. If the coils are entirely one over the other the outer one indi- 
cates o ; if it is drawn out one centimeter we speak of one centimeter 
spiral distance, etc. The more centimeters of spiral distance the 
weaker the current. Now it is clear that this designation of the 
strength of the secondary current according to the spiral distance is 
not absolute, as the strength of the secondary current depends upon 
that of the primary. The strength of the galvanic current is regulated 
in a rougher manner by var}^ing the number of elements. For finer 
alterations of the strength of the current a special apparatus called a 
rheostat is used, the handling of which is very simple. [The galvanic 
batteries now made in the United States and England usually have a 
rheostat as a part of the outfit. It is much better to use it, for two 
reasons : all the cells of the battery are drawn from alike, since all can 
be thrown into the current at the beginning of each sitting ; the grada- 
tions in the strength of the current are made without shock to the 
patient.] The strength of a current can be determined by a so-called 
absolute galvanometer, of which we will speak later on. 

The current is conveyed to the bod}^ by an electrode previously 
moistened with warm [preferably salt] water. In making the exam- 
ination, one of these is always the indifferent one — that is to say, it 
merely serves to close the current that is flowing through the body; 
the other is the '' differ e7itiating'' or examining one. For the selection 

^ Of course it is not necessary here to go into particulars. Hence we refer the reader to 
special works, particularly to Erb's classical work, Electro-therapy. 



EXAMINATION OF THE NERVOUS SYSTEM. 463 

of the size of these electrodes there are two very different determina- 
tive points of view. 

The one takes into account tJie resistances of tJie skin. This is by 
far the strongest of the resistances which the tissues of the body, with 
the exception of soHd parts of bones, offer to the current. But since 
the resistance diminishes in proportion to the square of the cross-sec- 
tion it is best to make both electrodes as large as possible in order to 
lose the least possible strength of current in passing through the skin. 

The other point of view is to some extent opposed to the first. 
As has been said above, since we have in view an irritation through 
the skin of nerves and muscles superficially situated, we must be 
careful to always have the greatest possible portion of the strength of 
current which the apparatus supplies expended for the irritation of 
the respective nerves or muscles. A sharp distinction must be made 
between " total-current-strength " and that portion of it which is em- 
ployed for the irritation, " irritation-current-strength." In order that 
the latter may constitute as great a proportion of the former as pos- 
sible, it is necessary in the passage through the skin to concentrate the 
current upon a conductor whose cross-section approximates as closely 
as possible that of the subcutaneous organ ; hence for the purpose of 
irritating a nerve the cross-section upon the skin must be very small ; 
therefore for the examining electrode we select one as small as pos- 
sible. But this fact, already mentioned, must be remembered, that the 
*' total-current-strength " is considerably diminished by the diminution 
of the cross-section of the current, just in the skin which in itself 
offers a strong resistance, and this is true with the galvanic current in 
a higher degree than with the faradic. For this reason, and especially 
on account of the disagreeable secondary effects of too dense a current 
(pain, cauterization of the skin), it is necessary in making examinations 
to select electrodes whose cross-section is somewhat larger than that 
of the nerves. 




Fig. 170. — " Fine " electrode of Erb (natural size). 

From this explanation it is evident that the " indifferent " electrode 
may be of indefinite size, hmited only by considerations of convenience. 
The " examining " electrode, however, must be small, and in examina- 
tions of the nerves and some muscles, if the faradic current is em- 
ployed, it may be very small. We recommend the fine sponge elec- 
trode of Erb, represented in Fig. 170. 

The galvanic current, on the other hand, does not permit the use of 
such small electrodes, because it is more sensitive to resistance and 
besides, by its greater density, it damages the skin. For this reason, 
in examining with the galvanic current, we employ a somewhat larger 
electrode. Now since we can always measure the total-current- 
strength of the galvanic current by means of a galvanometer,^ the 
attempt has been made to arrange conditions, which, upon the basis 

^ See below. 



464 SPECIAL DIAGNOSIS. 

of the "total-current-strength," furnish as exact conceptions as pos- 
sible of the '* irritation-current-strength," which is the only one for 
ultimate consideration. As everywhere else, so also in the passage 
through the skin, the density of the current is in inverse proportion to 
its cross-section. If the ** total-current-strength " and the cross-section 
of the current are known, the density of the current — that is, the 
strength of the current in terms of the unit of measure — may be best 
calculated pro square centimeter of the cross-section. Given an ex- 
amining electrode of a definite known cross-section, we may determine 
the density of the current in the passage through the skin in the 
manner indicated and thus form an at least approximate idea of the 
density and the strength of the current which is present in organs 
whose cross-section is approximately known and which lie directly 
under the skin (nerves, muscles). Examining electrodes of definite 
cross-section [as standards] have been constructed for the constant 
current for the purpose of getting as fair a relation between the " total- 
current-strength," the " total-current-cross-section," and the " irritation- 
current-strength," although this relation is only imperfectly known. 
Unfortunately there are several of these : but we take into considera- 
tion only the following : that of Erb, of 10 square centimeters cross- 
section (either square, 3.3 cm. on a side, or circular with a diameter 
of 3.5 cm. ; and that of Stinzing, round and somewhat convex, 3 
square cm. in cross-section and 2 cm. in diameter. With every 
record of an examination there should always be a statement of the 
size of the electrode employed. 

As yet we have no simple, practicable method for measuring the 
" total-current-strength " in making examinations with the faradic cur- 
rent, since the apparatus hitherto constructed for that purpose (faradi- 
meter) is too complicated and expensive. Under these circumstances 
nothing remains but to forego absolute dosage in making the faradic 
examination. The distance of the coils may be noted, which may sig- 
nify a different strength of current according to the construction of the 
respective sliding apparatus and the strength of the elements which 
furnish the primary current, but which, nevertheless, has a certain 
comparable value for the different examinations made with the same 
apparatus. Moreover, a certain exactness may be attained if, from time 
to time, the user tests the effectiveness of his own sliding apparatus at 
a given distance oi the coils upon a healthy person, best upon himself, 
for instance on the left ulnar nerve at the wrist, and if he observes the 
points discussed later on. Besides it is important to be certain in 
another direction : although the faradic current is less influenced by 
the resistance of the skin than by the galvanic, nevertheless an excep- 
tionally great, or exceptionally small, resistance of the skin at any 
given place of examination may so very much diminish, or relatively 
so much increase the strength of the current that the examiner con- 
siders that the irritability, for instance of a nerve, is considerably 
smaller, or greater, as the case may be, at such a place than it really is. 
In order to counteract this error we may determine the resistance to 
conduction for all points of the skin at which faradic irritation has been 
made by ascertaining the declination of the needle of a galvanometer 
when a galvanic battery with always the same number of elements 



EXAMINATION OF THE NERVOUS SYSTEM. 465 

has been inserted/ The judgment thus obtained in regard to the re- 
sistance of a spot of skin to conduction of the constant current may 
be transferred to the faradic current. It must be remembered, however, 
that only considerable deviations from the normal come into consider- 
ation for this latter current. 

The galvanic current, however, we measure directly, according to 

an absolute measure, in milliamperes, abbreviated, i M.-A.= , 

^ 1000 ohms 

(see text-books upon Physics). To ascertain the number of milliam- 
peres used we employ a so-called absolute galvanometer. The total 
strength of current indicated by the galvanometer is then divided by 
the transverse section of the examining electrode in such a way that, 
for example, with a total strength of 2.5 M.-A. and an electrode of 12 

sq. cm. transverse-section to a sq. cm. of the skin, a current of— M.-A. 

is given off; now, after what has been already said, this fraction is not 
an exact measure of the extent of irritation to which the nerve is sub- 
jected as it Hes buried beneath the skin, and generally also in a layer 
of fat of varying thickness ; but at any rate, it gives a result which is 
of value for comparison if applied in all examinations. If we employ 
a normal electrode, then we can note : Norm, electrode Erb (10 sq. cm.) 

2.5 M.-A., or ~ M.-A. (N. el. Erb). 

This comparison of the total strength of the current with the abso- 
lute measure is now-a-days indispensable : it has, it is true, only a 
value which is, in a certain sense, circumscribed. A difficulty which 
at present is tolerably successfully overcome consists in the fact that 
the conducting resistance of the skin for various reasons decHnes as 
the current passes through it, and therefore, although only in a slight 
degree, the strength of the current increases so long as the electrodes 
rest upon the body, and hence, also, from the moment when the 
galvanometer is switched in to the instant when the needle comes to 
rest. With the new galvanometers (especially Edelmann's horizontal 
galvanometer, but also with the instruments of Bottcher-Stohrer and 
Hirschmann), by an appropriate check, this space of time is satisfac- 
torily shortened. Stintzing is to be credited with very exact exami- 
nations regarding these points. 

A much more considerable difficulty, which has already been hinted 
at several times, and one which probably will never be satisfactorily 
solved, consists in the fact that we cannot concentrate our current upon 
the nerve or muscle to be examined, because, covered by the skin and 
partly also by subcutaneous fat and fascia, they lie in a medium which 
itself is a good conductor, which diverts to itself a part of the current. 
Furthermore, we cannot, even with the least accuracy, calculate how 
great is the portion of current which ultimately reaches the nerve or 
muscle ; for the situation of these structures with reference to the skin 
and their immediate surroundings is extremely variable at different 
parts of the body, and also in different individuals. On this account 
not only is the irritabihty of muscles and nerves as measured by the 

^ See below, 
30 



466 SPECIAL DIAGNOSIS. 

" total current-strength " influenced in an uncontrollable manner, but 
also, according to Erb's investigations, even the quality of the contrac- 
tions are affected. 

There follows from the foregoing, first of all, the practical point 
that, in spite of our ability to measure the strength of the total current, 
we are taught to bear in mind the individual peculiarities of the nerves 
(muscles) to be examined, in their relation to the skin, in interpreting 
the results of the examination, so as to supply, as far as possible, the 
want of exactness in our calculation ; and it follows, further, that it is 
superfluous, and even a source of error (because it withdraws our atten- 
tion from the more important points of view), if we strive after exact- 
ness in electrical examination by the fineness of the apparatus, espe- 
cially of the galvanometer — an exactness which, let it be said once for 
all, the examination cannot have. Of what use is it exactly to deter- 
mine the strength of the total current to within one-tenth of a M.-A., 
if the anatomical conditions of the nerve which is to be irritated cause an 
inexactness impossible to calculate amounting to whole milliamperes ? 

How to Distinguish the Poles Quickly. — In the faradic cur- 
rent the poles come but little into consideration — namely, only so far 
as to know that the cathode (the negative pole) of the opening current 
of the secondary coil has a stronger irritating effect than the anode 
(the positive pole). In the galvanic current the poles are widely differ- 
ent! They are always marked on the apparatus by the signs of plus 
and minus, but as they may be reversed by screwing on the conduct- 
ing wires in an opposite way, it is necessary to always test them anew. 
The simplest way is to employ a very mild current, and then to place 
the two electrodes upon the cheeks ; upon the side of the anode we 
experience a peculiar indefinable taste upon the tongue and the mucous 
membrane of the cheek of that side, while on the cathode side there is 
no sensation ; or we place the wires of both poles about I cm. apart 
upon a piece of wet blue litmus-paper : the anode colors it red. 

By a current-changer we are able to reverse the poles — that is, to 
quickly make the anode the cathode, and vice versa. 



METHODS OF EXAMINATION IN GENERAL, AND THEIR PHYSIOLOGICAL 
RESULTS UPON THE LIVING HUMAN BODY. 

As a foundation to what is here to be spoken of, we refer most 
urgently to the text-books upon physiology or upon electro-thera- 
peutics, especially to what is taught regarding electrotonus and the 
laws of contraction (Pfliiger). Unfortunately, we cannot enter upon 
these subjects here. [The student is referred to Landois and Stirling's 
Physiology for an excellent presentation of Electrotonus — law of con- 
traction.] 

The electrical examination consists in the production of muscular 
contractions by means of both kinds of current, and sometimes by irri- 
tation of the muscles themselves (direct irritation), and by irritation of 
nerves {indirect irritation). The latter is generally made before the 
former, and thus we have to make use of an indirect faradic and gal- 
vanic and a direct faradic and galvanic examination. As previously 
stated, the extent of the irritation is always a matter of uncertainty to us 



EXAMINATION OF THE NERVOUS SYSTEM. 467 

(distance of the coils ; total strength of the galvanic current in M.-A. is 
known). We draw our conclusions from the results of the examination : 

{a) From the degree of excitability of the nerve (muscle) by deter- 
mining with what strength of current there follows the first, smallest, 
just noticeable, or minimal contraction ; sometimes also by determining 
the extent of irritation which is necessary with the galvanic examination 
to cause a tetanic contraction. The minimal contraction is observed at 
the muscle or by the movement of the joint. The comprehension of 
these minimal contractions (still more of galvanic tetanus^) by the indi- 
vidual examiner is, to a certain extent, variable, and a source of inex- 
actness. 

(U) With reference to tJie quality of the reaction in the direct irrita- 
tion of the muscle with the galvanic current ; that is, the character of 
its contractions and its " law of contraction," regarding which we will 
speak more at length below. 

Since the electrical currents, except they be very strong, only stimu- 
late by sudden oscillations in the current, the faradic current, because 
it consists of a great number of opposing currents of short duration, 
causes a tetanic contraction proceeding from the nerve as well as from 
the muscle itself, which continues while the electrode remains with the 
current closed ; the galvanic current, on the other hand, indirect as well 
as direct, produces its effect only at the instant of its entrance. In both 
instances, if the current is sufficiently strong, contractions take place — 
the closure contraction at the instant of closing, the opening contraction 
at the instant of opening the current, and at the instant of its exit. But 
while with the nerve exposed (Pfliiger) at the cathode [represented 
hereafter by Ca] (negative pole), only the closing of the current, and 
at the anode (positive pole) [represented hereafter by An], only the 
opening of the current occasions a contraction, we find that with the 
nerves and muscles of the living man there is another law of contraction, 
which at first sight seems to contradict Pflijger's law, but the contradic- 
tion is easily explained if we consider the peculiar conditions of the ex- 
periment which are present in the living human body ; that is, in a 
nerve which is not exposed. Regarding this, as it were, " clinical law 
of contraction," we must now go a little more into detail: 

General Methods and Explanation of the Terms Employed 
in Galvanic Examinations. — The indifferent electrode is placed upon 
the sternum, the examining electrode (normal electrode) upon the nerve 
or muscle to be examined. With the current-changer we close the 
current so that the examining electrode is the cathode — that is, we 
make the "cathodal closure" Q2S\^ = Schliesting, closure]; there 
results a contraction, C, thus it is CaSC; then we open the current, 
thus making a cathodal opening, CaO : sometimes there is CaOC ; then 
with the current-changer we reverse and close the current, so that the 
examining electrode becomes the anode. An, making AnS : we some- 
times have AnSC, then likewise at the end AnOC. With a very strong 
current we have, upon CaS and with the current remaining closed, a 
tetanic contraction : CaSTe. 

1. Stimulation of Nerves. — These opening and closing contractions 
at the cathode and anode do not all of them occur with the same 

^ See this. 



468 SPECIAL DIAGNOSIS. 

strength of current. On the contrary, if we begin with a weak current 
and under continuous closing and opening at both poles we increase 
the current, we first notice that there is a slight contraction, when at a 
certain strength we close the current in such a way that the examining 
electrode becomes the cathode ; that is, as soon as we make the cathodal 
closure, CaS. Then, while keeping the same strength, if we open the 
current (CaO) no contraction follows, and this is also true if we reverse 
and close and open at the anode (AnS, AnO). If the current is further 
increased we see a corresponding, more pronounced CaSC, but with a 
certain strength of current there also now results a contraction with 
AnS, and then usually also immediately with AnO : AnSC, AnOC ; as 
yet at the cathode there is never any result. Only when the current is 
very strong, under which the cathode-closure-contraction changes to 
tetanus (CaSTe) there is a weak contraction with the cathode opening. 
All these contractions, whether weak or strong, are short, lightning- 
like. The CaSTe is of course an exception to this. It consists of a 
rather short tetanic continuance of the lightning-like CaSC. 

From this there results the following scheme of the laws of normal 
contraction with galvanic stimulation : 
Nerve x : 

{a) Weak current : no contractions at all ; 

{li) Current a little stronger : CaSC gives feeble, short contractions ; 

CaO negative ; 

AnS 

AnO 
ic) Strong current : CaSC gives strong, short contractions ; 

CaO negative ; 

AnS gives feeble, short contractions; 

AnO " 
id) Very strong current: CaS " tetanus of short duration ; 

CaO ** feeble, short contractions ; 

AnS '' stronger," 

AnO " 

Or also, in brief: with a certain moderate strength of irritation there 
is CaSC and AnSC (AnOC is not taken into account), but CaSC is 
greater : CaSC>AnSC. 

The contractions are, all of them, short, lightning-like. 

2. Stimulation of Muscles. — In this case, as far as possible, we avoid 
a simultaneous irritation of motor nerves, especially the one which 
supplies the muscle being tested. The electrode is, therefore, placed 
as far as possible from mixed and motor nerves, particularly from the 
place of entrance into the muscle. We then find that with a moderate 
strength of current CaSC takes place, and that a slight increase is 
sufficient to cause AnSC ; on the other hand, that AnOC frequently, 
also CaOC almost always, does not occur even with the strongest 
currents. 

It is remarkable that the effaceable closure-contractions, especially 
AnSC, are not quite so short as those which are produced from the 
nerves. This is very striking in some individuals, less so in others. 



EXAMINATION OF THE NERVOUS SYSTEM. 469 

The examination here also normally may be briefly stated as 
follows : with x M.-A CaSC>AnSC, with the additional statement : 
contractions very short, or AnSC a trace slower than CaSC. 



METHOD OF EXAMINATION IN DETAIL.— NORMAL CONDITION. 

Preliminary Remarks. — In examining individual nerves and muscles 
we must strive most earnestly to employ exactly similar methods. In 
the first place, in examining nerves, we should use Erb's fine electrode 
for the faradic current, and either Erb's or Stintzing's normal electrode 
for the galvanic current. With the galvanic current especially we 
should always make about the same pressure upon the electrode, in- 
creasing the pressure only when there is a very firm layer of fat, in 
order in this way to equalize to some extent the effect of the fat-layer. 
We are always to examine homonymous parts together ; that is, the 
right, then the left radial, the right, then the left median ; or, when the 
disease is unilateral, the nerve (muscle) of the sound side always first. 

I. Points of Stimulation. — In what follows we ^w^ the points of 
stimulation of the nerves and the so-called motor points of the mus- 



M. frontalis 

Upper branch of 
facial 
M. corrug. 
supercil. 

M. orbic. palpebr. 

Muscles of the f 

nose \ 

M. zygomatici 
M. orbicul. oris < 

Middle branch of 
facial 

M. masseter 

M. levator menti 

M. quadr. menti 

M. triang. menti 

N. hypogloss. 

Lower branch of 

facial 

M. platysma 

myoides 

Muscles of the f 

root of tongue ( 



M. omohyoideus 



N. thoracic, anter. 
(M. pector.) 




Region of central 
convolutions 



Region of the 
third frontal 
convolution 

M. temporalis 

Upper branch of 
facial in front 
of ear 

N. facialis 

N. auriculo. post. 
Middle branch of 

facial 
Lower br. of facial 
M. splenius 

M. sternocleido- 

mastoideus 
iV. accessorius 

M. levator anguli 

scapulae 
M. cucullaris 

iV. dors, scapulas 



N. axillaris 



N. thoracic, long. 
(M. serratua 
antic, maj.) 



N. phrenicus Suprascapular Plexus 

point. (Erb's point. brachialis 
M. deltoid., biceps, 
brachial, intern, and 
supinat, long.) 

Fig. 171. — Points of electrical irritation upon the head and neck (Erb). 



cles (for which we are indebted to the investigations of Duchenne, 
V. Ziemssen, Erb ; the illustrations are taken from Erb's Electro-thera- 



470 



SPECIAL DIAGNOSIS. 



peiitics. These points frequently correspond to the points where the 
nerves enter the muscles, and hence are essentially also the nerve- 
points. In examining the muscles themselves we place the electrode 



M. triceps (caput 

longum) 



M. triceps (caput 
intern. ) 



Nerv. ulnaris 



M. flexor carpi ulnaris 



M. flex, digitor. com- 
mun. profund. 



M. flex, digitor, sub 
lim. (digiti U et III) 



M. flex, digit, subl. 
(digit, indicis et 
minimi) 

Nerv. ulnaris 



M. palmaris brev. 

M. abductor digiti 

min. 

M. flexor digit, rain. 

M. opponens digit. 

min. 

M. lumbricalesK 



V Nerv. medianus 
jM. supinator longus 
M. pronator teres 




M. deltoideus 

Nerv. musculocutanetts 
M. biceps brachii 
M. brach. internus 



~ M. flex, carpi radialis 
M. flexor digitor. sublim. 

M. flex. poUicis longus 
Nerv. medianus 

M. abductor pollic. brev. 
_ M. opponens pollicis 

M. flex. poll. brev. 

M. adductor pollic. brev. 



Fig. 172. — Points of electrical irritation upon the arm (Erb). 

upon the fleshy part of the muscle, avoiding, as far as possible, both 
of these related points. 

The points most distinct in the figure correspond to the chief places 
for applying the stimulation. In the faradic examination we seek 



EXAMINATION OF THE NERVOUS SYSTEM. 



471 



carefully in the course of the nerve for these most excitable points ; 
that is, for those places where they lie nearest the skin. 

Remarks regarding Fig. 171 : We observe particularly the upper, 
middle, and lower facial (the three most distinct points upon the face). 
At the brachial plexus we notice Erb's point [the supraclavicular point], 
from which the following named muscles may be simultaneously stimu- 
lated : deltoid, biceps, brachiahs anticus, and the supinator longus. 



M. deltoideus 



N. radial is 
M. brachial, intern. 

M. supinator long. 
M. radial, ext. long. 
M. radial, ext. brev. 



M. extensor digit, communis 
M. extensor indicis 
M. abductor pollic. long. 
M. extensor pollic. brev. - 



M. inteross. dorsal. I et II 




M. triceps (caput longum) 



M. triceps (caput ex- 
tern.) 



M. ulnar, extern. 
M. supinat. brev. 

M. extens. digiti minim. 
M. extens. indicis 

M. extens. poll. long. 



M. abduct, digit, min. 



M. inteross. dorsal. Ill 
etIV 



Fig. 173. — Points of electrical irritation upon the arm (Erb). 

The tongue and soft palate will be best directly irritated with an 
electrode that is isolated as far as to the end (which may be done 
by simply winding it with adhesive plaster). 

A strong galvanic airrent should never be used npon the head. 

Remarks regarding Figs. 172 and 173 : We examine the arm in the 



472 



SPECIAL DIAGNOSIS. 



position of moderate flexion and slight pronation, but the muscles are 
to be relaxed (hence the arm must rest comfortably). 

The radial nerve lies deeply, especially if the muscles are well devel- 
oped. The ulnar nerve lies in the sulcus of the internal condyle of the 
humerus, and can be felt with the finger here and for some distance 
upward. 

Position of the Indifferent Electrode. — In stimulating the radial nerve 
and the ulnar and median at the elbow it is best to place the indifferent 
electrode upon the sternum ; on the other hand, for the ulnar and 
median at the wrist-joint it is best to place it on the dorsal side of the 
wrist; and this also is the point most favorable for stimulation of all the 
muscles of the forearm and hand, because it excludes any accessory 
stimulation. 

Remarks upon Figs. 174-176: It is very difficult to stimulate the 
ischiatic nerve. It can only be done by pressing the electrode in 



N. cruralis 

JV. oblvrator 
M. pectineus 

M. adductor magnus 
M. adduct. longus 

M. cruralis 
M. vastus internus 




VM. tensor fasciae latse 

M. sartorius 

M. quadriceps femoris 

M. rectus femoris 



Im. 



vastus externus 



Fig. 174. — Points of electrical irritation upon the upper part of the thigh (Erb). 



deeply and employing a strong current. We can easily find the pero- 
neus nerve if we feel for the head of the fibula and go inward and 
upward from this. 

Upon the back, since the nerves almost nowhere lie sufficiently near 
the surface to permit of indirect examination, we have to do almost 
exclusively with direct muscular irritation. It is superfluous to make 
more exact statements regarding the simple topographical relations. 



EXAMINATION OF THE NERVOUS SYSTEM. 



473 



2. Method of Conducting the ]^xamination. — We demonstrate 
this upon a single nerve-muscle, and for this we take the radial. We 
always begin with the faradic current, and this for good reasons, which 
have recently been made more strong (relations of the " resistance to 
conduction " — Stintzing), which we cannot enter upon here. 

{a) Faradic Examination. — (a) Nerve. — The indifferent electrode 
is placed upon the sternum, the examining electrode, that is, Erb's 
" fine " electrode, held as a pen in writing, is placed upon the radial 
nerve [the musculo-spiral] where it turns round the humerus in the 
middle of the arm : here tolerably deep pressure is necessary. The 
induction coil is now pushed out till the minimal contraction is pro- 
duced ; in doing this we should feel for the nerve with the electrode, 
which can only be learned by practice, and cause it to twitch : it is at 



\ M. gluteus maximus 



Nerv. ischiadicus 

M. biceps fern. (cap. long 
M. biceps fern. (cap. brev.) 



N. peroneus 
gastrocnem. (cap. extern.) / — ^ 

M. soleus 



M. flexor hallucis longus 




M. adductor maguus 
M. seraitendinosus 
M. semimembranosus 



N. tibialis 

M. gastrocnem. (cap. int.) 
M. soleus 

M. flexor digitor. comm. longus 

N. tibialis 



Fig. 175. — Points of electrical irritation upon the back of the lower extremity (Erb). 

that instant that the minimal contractions usually take place. The 
distance to which the induction coil is pushed out is now read off and 
noted : for instance, " minimal contraction," or, abbreviated, " C, in the 
extensors and supinator," or " in the supinator alone with S. D. (spiral 
distance) of 120 mm." 



474 



SPECIAL DIAGNOSIS. 



Then the resistance of the skin to conduction at the points where 
the indifferent and examining electrodes were placed must be deter- 
mined. For this purpose the fine electrode is changed for the normal 
electrode, which latter is put upon precisely the same place where the 
stimulation was applied ; ten elements of the galvanic battery are put 
in circuit, and the declination of the needle on the absolute galvanometer 

read at the instant when the two electrodes have been on for just 



is 



thirty 
It is 



seconds with 
necessary, 



the current closed. 

we have before emphasized, to determine the 



as 



M. tibial, antic. 

M. extens. digit, comm. 
long. 



M. peroneus brevis 



M. extensor hallucis 
long. 



Mi. interossei dorsales 




Nqtv, peroneus 



M. gastrocnem. extern. 
M. peroneus longus 



M. flexor hallucis long. 



M. extens. digit, comm. 
brevis 



■— M. abductor digiti min. 



Fig. 176. — Points of electrical irritation upon the leg (Erb). 



" conductive resistance " exactly in the manner described by Erb. The 
fluctuations in the conductive resistance, and with it (in an opposite 
sense) the strength of the total current, are, in fact, during the exami- 
nation veiy slight, and can ordinarily, as has been shown most accu- 
rately by Stintzing, be neglected. But in some cases it happens that 
at the point of examination the skin is very tender or abnormally dense ; 
in which case, of course, with the same separation of the coils of the 
same apparatus, we have relatively a stronger or relatively a weaker 
current, and we find a minimal contraction with a large or with only a 
very slight conductive resistance. This result we would refer to an 
increased or diminished irritability of the nerve if we had not ascertained 
by the galvanic determination of the " conductive resistance " that the 
skin was the cause of the variation. Extremely instructive examples 
illustrating this point are given by Erb in his Electro-therapetitics. 



EXAMINATION OF THE NERVOUS SYSTEM. 475 

In Other words : whenever we are making an electrical examina- 
tion we must know what strength of total current we are employing. 
Since we are not able with a simple method to determine this directly 
with reference to the faradic current, we must endeavor to form an 
opinion of the total strength of the faradic current (with a certain 
definite separation of the coils) by bearing in mind the total strength 
of the galvanic current which is caused by a certain number of ele- 
ments (always the same). 

If we examine a number of nerves at the same time, we first de- 
termine the minimal contraction for all, and then the conductive resist- 
ance ; and after we have examined the nerves we can at once make the 
faradic examination of the muscles. 

It is always well to follow the faradic examination with the galvanic, 
and in this way, with a good deal of practice, we can form an opinion 
regarding the relation of the conductive resistance at the different 
points of stimulation of the nerves, and can make a counter-judgment 
regarding the faradic result by a comparison of the number of ele- 
ments used each time and the absolute strength of current that is 
obtained. But then there must always be given in the record of the 
galvanic examination both the number of elements and the strength 
of the current in M.-A, 

We wish that the direction given above, that the galvanometer 
should be read when the electrodes have been in place just thirty 
seconds, could be carried out in all efforts at electro-diagnosis, because 
otherwise the marked increase of the current at the beginning, just 
after the electrodes have been applied, could easily occasion great 
inequalities. 

(/:9) Muscles Supplied by the Radial [Musculo-spiral] Nerve. — We use 
a somewhat larger electrode, stimulate the fleshy part of the individual 
muscles, and, lastly, determine the minimal contraction ; the determina- 
tion of the conductive resistance is not necessary. 

Under some circumstances there comes into consideration the 
quality of the muscular contraction in indirect and direct faradic 
stimulation. (See under Reaction of Degeneration, page 478/.) 

{b) Galvanic Examination. — (a) Nerve. — Place the indifferent elec- 
trode upon the sternum and the examining electrode (with somewhat 
strong pressure) upon the radial [musculo-spiral] nerve where it passes 
around the humerus ; close the cathode three times ; if the result is 
still negative, increase the number of elements ; again close the cathode 
three times, and so on until the minimal contraction is found. Then 
switch in the galvanometer and read off the strength of the total cur- 
rent. (Galvanometers that have a very good arrangement for damping 
the vibration of the needle can remain switched in during the examina- 
tion.) Now determine the minimal AnSC in the same way (but it may 
be omitted). Usually we may be satisfied with this. The next point 
of interest would be the determination of CaSTe. (Regarding varia- 
tions in the quality of the reaction, see under Reaction of Degeneration.) 

(/?) Muscles of the Radial. — We proceed as in the case of the nerves, 
but sometimes we may place the indifferent electrode upon the wrist, 
dorsal side.^ It is always necessary to determine the minimal CaSC 

1 See below. 



476 



SPECIAL DIAGNOSIS. 



and minimal AnSC ; but, before all, the most exact observance of the 
character of the contraction,^ whether it is " lightning-like " or " slow," 
and in this direction we not only observe the minimal contraction, but 
also whether it is a stronger or strong contraction. 

Summarized, the scheme of examination — for instance, in dimin- 
ished irritability of the left radial nerve — would be as follows : 

{a) Faradic examination : 

(«) Nerv. radial, r. 120 S.-D.^ (extensors and supinator): variation of 

needle, ten elements, 6 M.-A. 
Nerv. radial. 1. ^J S.-D. (extensors alone), 

80 S.-D. (supinator longus) : var. needle, 
ten elements, 4.5 M.-A. 
(/3) Muscles of the nerv. radial, r. : C. (contraction) at about 80 S.-D. 

ib) Galvanic examination (normal electrode, Erb) : 

(«) Nerv. rad. r. CaSC, 2.3 M.-A. ; 1. CaSC, 6.0 M.-A.^ 
(/9) Muscles (extensors and supinator) : 

r. at 3.5 M.-A.; CaSC > AnSC, C, short; 

1. at 7.0 M.-A.; CaSC > AnSC, C, short. 

3. What to Observe in Determining the Blectrical Re- 
action. — We examine in two main directions : (a) the quantitative 
excitability or degree of excitability of the nerves and muscles ; {6) the 
qualitative excitability of the muscles under galvanic stimulation. 

{a) Quantitative Excitability. — Its diminution in the most marked 
degree — namely, loss of excitability— is easily recognized. To the 
record is always to be added : " Lost when the coils of the induction 
apparatus were separated to a distance x, or for a current of x M.-A." 
On the other hand, it is difficult to define the limits between the 
normal and pathological in simple diminished or increased excitability, 
particularly of the nerves. We can take different ways to arrive at a 
conclusion in this regard : 

in) We compare the two halves of the body. This is very much 
the more certain way, but of course is only applicable in cases of uni- 
lateral disease. Normally, the differences between the two halves of 
the body are very slight. The maximal differences for the nerves and 
with the galvanic current, according to Stintzing (58 healthy persons ; 
Stintzing's normal electrode of 3 sq. cm.), are: 

Ram. frontal. N. VII 0.7 M.-A. 

N. accessorius o. 1 5 " 

N. medius 0.6 " 

N. ulnaris 2^^ above the olecranon 06 " 



N. radialis -, . . . i.i M.-A» 

N. peroneus 0.5 " 

N. tibialis 1. 1 " 



Y OX faradic excitability the difference for the two sides of the body, 
at least for the four pairs of nerves that come especially into consider- 
ation, rami frontal, (facial.), N. accessorius, ulnaris, peroneus (see 
below), is, according to Erb, scarcely ever greater than 10 mm. separa- 

^ See under Reaction of Degeneration. 

2 Fully expressed : right radial nerve, minimal contraction at 120 mm. spiral distance. 
^ This is the minimum, which must be given. A complete statement would be, if 
noted : for instance, r. : CaSC, 2.3 M.-A., AnSC, 3 M.-A., etc. 



EXAMINATION OF THE NERVOUS SYSTEM. 



A77 



tion of the coils of his Dubois induction apparatus ; according to 
Stintzing, the maximal difference of all the pairs of the body that are 
accessible for examination is 15 mm. 

A difference which approaches this maximal difference must lead 
one to think of a pathological condition ; a difference that is materially 
greater is certainly pathological. But whenever a difference is found 
we must always consider whether the two homonymous nerves are 
situated exactly alike (malformation of the bones, etc.).^ 

(/3) We are to observe the relation which exists between the irri- 
tability of the N. frontalis (facialis), accessorius, ulnaris (at the elbow), 
peroneus, according to Erb's method. 

These nerves, but especially the ulnaris and peroneus, show only 
slight differences in health, as the following table, taken from Erb's 
Handbook, shows : 

Faradic Current, 

I. Healthy person, mechanic, age thirty-eight years : 





Distance of coils in mm., 
minimal contractions. 


Variation of galvanometer 
(old one), ioelen\ents. 


N frontalis 


r. 165 
172 

160 


1. 166 
177 
158 
163 


r. 18° 
16° 

6° 
5° 


1. 19° 

15° 
6° 


N. accessorius 

N. ulnaris 


N. peroneus 


9° 



2. Healthy person, laborer, age twenty-four years : 



N. frontalis 
N. accessorius 
N. ulnaris . . 
N. peroneus . 



Distance of coils in mm. 
minimal contractions. 



r. 195 

187 

135 
180 



1.192 
182 
185 
180 



Variations of galvanometer 
(old one), lo elements. 



Galvanic Current. 

Healthy men, thirty-eight and twenty-four years of age. 
electrode, 10 sq. cm.) : 



(Normal 





Occurrence of the first 
CaSC. 


Occurrence of the first 
CaSTe. 


N. frontalis 


r 1.4 M.-A. 
0.5 " 
0.4 " 
1-5 " 


1. 1.2 M.-A. 
0.5 " 
0.4 - 
1-5 " 


r. 8.0 M.-A. 
4-0 " 
6.0 " 
7.0 " 


1. 8.0 M.-A 


N. accessorius 

N. ulnaris 


4.0 " 

5-5 " 
7.0 


N. peroneus 



By studying these tables we ascertain from them the relation be- 
tween these four pairs of nerves as to the extent of their irritability, and 

^ See above. 



47 S SPECIAL DIAGNOSIS. 

it is possible to recognize with greater certainty a bilateral variation, 
especially of the ulnar or peroneus nerves. 

(7) Lastly, Stintzing has given the " limits of value " for the irrita- 
bility of nerves ascertained in the case of 58 healthy persons (Edel- 
mann's galvanometer, normal electrode 3 sq. cm). But these figures 
are only of value for Stintzing's normal electrode. They are the 
following : 

N, ulnaris ....... 0.2-0.9 M.-A. 

2'^ above the olecr. 

N. radialis 0.9-2.7 " 

N. peroneus 0.2-2.0 " 

N. tibialis 0.4-2.5 " 



R. front. N. fac. . . . 


. . 0.9-2.0 M.-A 


R. zygomat. N. fac. . . 


. . 0.8-2.0 " 


R. ment. N. fac. . . . 


. . 0.5-1.4 " 


N. accessorius .... 


. . 0.1-0.44 " 


N. medianus 


. . 0.3-1.5 " 



In individual cases, however, Stintzing has found still smaller or 
larger figures. As they are to be regarded as exceptions, he calls 
them *' extreme values." Possibly some of them are of a pathological 
nature. 

Except in the reaction of degeneration^ the quantitative irritability of 
the muscles very often goes quite parallel with that of the nerves. We 
can endeavor to determine this by estimating it. 

{b) Qualitative Irritability of Muscles from Galvanic Stimulation. 
— Although with respect to the nerves in general we are only interested 
in the strength of current required to produce the first occurrence of 
CaSC and CaSTe, since the law of contraction of the nerves is that 
normally the character is almost always lightning-like in the direct 
galvanic stimulation of the muscles, two important variations come into 
consideration : they concern the cliaractej' of the contraction and the 
relation of the contractions to each other, and, further, tJie law of con- 
traction, and particularly the relation between CaSC and AnSC But 
the first point of view is much the more important. 

There are two classes of pathological galvanic muscular reactions : 
I, tJie reaction of degeiteration (RD), the exclusive attribute of degen- 
erative-atrophic paralysis ; 2, the myotonic reaction, which occurs solely 
in Thomsen's disease. 

1. Reaction of Degeneration (RD). — It is necessary to remember 
that normally the contractions which follow direct galvanic stimulation 
are either just as short and lightning-like as those resulting from irrita- 
tion of the nerve, or at any rate only a trace slower, which slowness 
is relatively most frequently noticed with AnSC. Notice further that 
normally with a medium strong current, one which suffices to produce 
CaSC as well as AnSC, we find the CaSC greater than AnSC (CaSC > 
AnSC). 

By reaction of dege7icration (RD) is understood a complex phe- 
nomenon whose most striking peculiarity is a slow, vermiform contrac- 
tion in direct galvanic stimulation and then by the occurrence of abnor- 
mally pronounced AnSC compared with CaSC. These anomalies are 
associated with diminished or even complete loss of irritability of the 
nerves for both currents, and corresponding behavior — that is, dimin- 
ished or lost irritability of muscles — for the faradic current. 

The slowness of the contractions produced in muscles by the con- 

1 See this. 



EXAMINATION OF THE NERVOUS SYSTEM. 479 

stant current, in pronounced cases, is most extraordinary, catching the 
eye at once. The contractions of the muscles are actually vermiform, 
the movements in the respective limbs are correspondingly slow ; 
the contractions may be quite extensive, but the natural force is 
always diminished. Reaction of degeneration (RD) is most easily 
recognized when combined with increased galvanic muscle-irritability, 
which is particularly the case in acute and anterior horn paralysis 
setting in acutely and affecting whole muscles or groups of muscles. 
The beginner is frequently astonished at the contrast between the 
lost or much diminished nerve irritabiHty and the increased muscle 
irritability. 

It is more difficult to recognize correctly reaction of degeneration 
(RD) if either the muscle irritability is on the whole much lowered, 
as it is especially seen in older paralysis, or if it occurs in muscles 
some parts of which react normally while other parts give RD — the 
normal and diseased bundles being mixed. The latter is a peculiarity 
of disseminated paralysis — as, for instance, spinal progressive muscular 
atrophy and some forms of neuritis. 

Where reaction of degeneration (RD) is just developing, or at any 
rate where it is not pronounced, there AnSC is sometimes distinctly 
manifested by greater slowness than CaSC. Moreover, in such cases 
we often observe that weak muscular contractions better disclose the 
slowness than stronger ones. 

If we remember that sometimes also in health the direct galvanic 
contraction lasts a somewhat shorter time, that is, executes its motion 
somewhat slower, than the contraction produced from the nerve, from 
this the important conclusion is drawn that slight traces of RD are 
sometimes not easily recognizable. In fact, for this considerable prac- 
tice and experience are needed. 

Increase of AnSC against CaSC is manifested by the circumstance 
that AnSC occurs either with currents of equal strength or even 
with weaker currents than CaSC; therefore, CaSC = AnSC, or even 
AnSC > CaSC. But since also normally AnSC produced directly is 
occasionally found to be equal to CaSC, and even greater than the 
latter, this peculiarity of reaction of degeneration (RD) is less positive 
for diagnosis. 

Complete 3.nd partial reaction of degeneration are expressions used to 
designate the condition where, together with the existence of direct gal- 
vanic reaction of degeneration, the irritability of nerves and the faradic 
irritability of muscles is completely lost or is only diminished. 

From what has been said we make the following schemata : 

(a) Complete RD. — The electrical examination gives the following 
results : 

Faradic : 

nerves : I =0; that is, irritability (I) lost; 
muscles : I = o ; that is, irritability lost. 
Galvanic : 

nerves : I = o ; that is, lost ; 
muscles : slow, tonic, vermiform contractions : 
the quantitative irritability about normal or increased or diminished ; 
AnSC occurs with a less strong current than the CaSC, and with a 



48o 



SPECIAL DIAGNOSIS. 



less strength of current from which both take place AnSC is greater 
than CaSC : AnSC > CaSC. 
(li) Partial EaR. 
Faradic : 

nerves : diminution of I ; 
muscles : diminution of I. 
Galvanic : 

nerves : diminution of I ; 
muscles : RD as above. 
For more ready comprehension we add here two curves from Kast, 
which graphically exhibit the normal muscular reaction and the RD. 




Fig. 177a. 



-Healthy young girl ; stimulation of the muscles in the region of the peroneus ; 33 
cells. Ka = CaSC ; An = AnSC (after Kast). 




Fig. \T]b. 



-Case of poliomyelitis anter. chronic, same muscles as above ; 40 cells. Contrac- 
tions tardy, AnSO CaSC (after Kast). 



Course of RD. — RD is the pathognomonic sign of those changes 
which take place in muscles or motor nerves and muscles when they 
cease to stand under the peculiar trophic influence of their anterior 
horn gangha — those alterations we designate as degeneration of the 
nerves and muscles. This degeneration can be most beautifully 
studied by the electrical phenomena if a nerve-trunk is, at some place, 
suddenly interrupted throughout its whole transverse section. When- 
ever there is such an interruption there is manifest a complete separa- 
tion of the portion of the nerve of the muscles located peripherally 
from the anterior horn, which must inevitably lead, not only to paraly- 
sis, but also degeneration of the portions cut off, and with it RD. 
But now the case can either proceed so far that there is a permanent 
interruption at the injured spot which results in complete atrophy of 
the nerves and muscular fibers, or, after a time, the conduction at this 
place may be restored ; and in the latter case there is a return of the 
tissues of the nerves and muscles to the normal condition ; that is, 
there is regeneration of them. Now, according as the degeneration of 
the nerve (muscle) is complete on the cross-section or only partial, 
further, according as the degeneration is complete, it results in atrophy 
{i. e. transformation into connective tissue), or it again regenerates and 
returns to its normal condition, the RD shows a definite result as 



EXAMINATION OF THE NERVOUS SYSTEM. 48 I 

such, and also in its temporary behavior with reference to the ability 
to use the muscles within a given number of weeks or months. This 
course of RD in its relations to the alterations of the nerves and mus- 
cles is so well known that it can be used for a retroactive conclusion 
in regard to the latter. 

It is to be noted that RD does not occur with primary disease of 
the muscles or with central diseases situated above the trophic centers.^ 

As regards peripheral paralysis the different forms of RD have their 
separate diagnostic significance. The prognosis for restitution is unfa- 
vorable in proportion to the extent and completeness of the RD. 

A form of paralysis which occurs in all forms and degrees of severity 
is the so-called rheumatic facial paralysis. In this Erb, for the first 
time, recognized the relation of reaction of degeneration (RD) to the 
course of paralysis. We introduce here the schematic representation 
which he has given of its course. 

Fig. 178a gives a representation of complete RD with reference to 
motility, and faradic and galvanic irritability of the nerves and muscles ; 
and over it are given the designations of the simultaneous histological 
changes. The figures above the abscissae signify the duration, and the 
height of the ordinates of the different curves indicates the degree of 
irritability. Where the respective curves sink below the abscissae the 
irritabihty is extinct. The line of galvanic muscular irritability is wavy 
so long as the qualitative changes exist — that is, RD slowness of con- 
traction and predominance of AnSC. 

Degeneration Atrophy, etc. Regeneration, 

of nerves. of muscular fibers. 



1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Weeks. 
Motility. 



Far. 






Galv. 

Far. 

;^ (. Irrit. 





1 


1 


|||H 



Fig. 178a. — Paralysis with early return of motility (Erb). 



The motility is quickly completely lost ; soon after the nerve irrita- 
bility and the faradic muscle irritability diminish and are extinct after 
a fortnight. The galvanic muscle-irritability at first diminishes, but 
then with the signs of RD greatly increases. The first trace of motility 
appears at a time when there is still complete RD. One week later the 
faradic and galvanic irritability of the nerves reappears ; hence there 
now is partial RD ; three weeks later the slowness of the contractions 
begins to disappear. Diminished irritability of the nerves and motility 
continues a still longer time. 

With reference to time the condition is hke that in Fig. 178a. Here 
also for some time there is a partial RD, All the evidences of regen- 
eration return later. 

1 See p. 484. 
31 



482 



SPECIAL DIAGNOSIS. 



Motility, irritability of the nerves, and faradic muscular irritability 
do not return. Reaction of degeneration exists first, with increased 
muscular irritability. The galvanic muscular irritability in the course 



Degeneration of Atrophy, etc. 

nerves. of muscles. 



Cirrhosis. Regeneration. 




% ( Galv 
%\ &Far 
^ y Irrit 



Fig. 178b. — Paralysis with later return of motility (Erbj. 

of some months becomes nil ; the contractions, so long as they are still 
possible, are slow. 

The faradic and galvanic irritability of the nerves and faradic 



Degeneration 
of nerves. 



Atrophy ; nuclear proliferation ; cirrhosis. Total atrophy. 

70. 80. 90. 100. Weeks. 



3. 10. 20. 30. 40. 50. 60. 



Motility. 
4^' r Galv. 



{ 



Far. 



i { Galv. 

Si & Far- 
^ t Irrit. 




Fig. 178c. — Irremediable paralysis (Erb). 



irritability of the muscles diminish only to a sHght degree. Motility 
returns again quite early. 



Nerve ? 



Degenerative atrophy 
s of muscular fibers. 



Regeneration. 



Weeks. 




Fig. I78d. — Paralysis in which there is only partial EaR (Erb). 



EXAMINATION OF THE NERVOUS SYSTEM. 483 

Varieties of RD. — (a) Partial RD is necessarily accompanied with 
slowness of contractions (which are also indirect — Erb). Not only the 
contractions which occur with direct galvanic irritation of the muscles, 
but all contractions, including those also which occur with galvanic and 
faradic stimulation of the nerves and fa radio stimulation of the muscles, 
are slow in their character. [" The faradic excitability of the paralyzed 
muscle undergoes a diminution corresponding to that of the nerve, but 
the galvanic excitability of the muscles manifests the quantitative and 
qualitative changes w^iich are characteristic of the severer forms of the 
reaction of degeneration."] 

{b) The AnSC of the nerves is slow, the CaSC is not (Lowenfeld), 
or the muscle has a slow faradic reaction, while the nerve does not 
respond at all (Stintzing) ; or the muscle has a slow, the nerve a 
prompt, faradic reaction, etc. 

Stintzing and others, with the greatest pains, have recently under- 
taken to bring order out of this confusion with remarkable, although 
with few, results. However, no considerable progress in differential 
diagnosis and prognosis of the cases has resulted from these labors, 

{c) Mixed Electrical Reaction. — We thus designate those electrical 
reactions which occur when a muscle is partly degenerated and partly 
normal, and a corresponding portion of the nerves is also sound and 
another portion degenerated. Then we find a diminution, but never a 
loss, of faradic and galvanic excitability of the nerves and of faradic 
excitability of the muscles. But the direct galvanic muscular reaction 
causes the greatest difficulties : the contractions are not exactly short, 
not altogether slow, AnSC = CaSC, here and there also shorter : it is 
hard to discover its significance. All of this is not easy to understand, 
because normal contractions are mixed with RD ; especially difficult 
is it if, as is almost always the case, the excitability is lowered. The 
object is sometimes attained by making repeated, indeed daily, tests 
(when it seems that RD often becomes more distinct) by thorough 
examination of every part of the muscular system with weak as well as 
with moderately strong currents, and frequently changing the location 
of the indifferent electrode (which must always be done in such a way 
as to avoid exciting the nerves). 

A single clear manifestation of RD in one muscle or in a bundle 
of muscular fibers will usually serve as an indication of the whole dis- 
ease as degenerative atrophic paralysis. It is true that RD has twice 
been found in myopathic muscular atrophy in single muscles (Schultze 
and Zimmerlin). We (with Erb) do not share the opinion of Wernicke 
that this mixture is the single cause of every case of partial RD. 

2. Myotonic Reaction (Erb). — Myotonia congenita occurs in the very 
powerful (hypertrophic) muscles which always exist with this disease ; 
they show increased irritability and continuance of the contraction with 
the faradic current ; with the galvanic test likewise there is increased 
irritability, but only contractions as the current is closed, and then 
extremely slow and continuing contractions with peculiar formation of 
furrows and depressions. Stable-acting currents (the stimulating elec- 
trode placed not upon the muscle, but on the vasti, for instance, near 
the patella) produce rhythmical wave-fike contractions from the cathode 
toward the anode. 



484 SPECIAL DIAGNOSIS, 

In one case Jolly found that if without greater pauses we irritate 
repeatedly by the galvanic and faradic current, the duration of the 
after-continuing contraction always becomes shorter ; the after continu- 
ation finally disappears altogether. This is a very interesting analogue 
to the behavior of myotonic muscles in active contraction. 

3. Diagnostic Value of the Electrical Condition. — {a) Significance of 
Reaction of Degeneration. — The reaction of degeneration (RD) occurs 
— I. In all paralyses produced by disease of the ganglion-cells of 
the gray anterior columns of the spinal cord or of the motor 
nerves of the bulb. 2. In all paralyses produced by disease of the 
anterior roots and of the motor fibers of the peripheral cerebro-spinal 
nerves, where the trophic influence of the anterior-horn ganglia fails on 
account of the interruption of the conduction, peripherally, in the nerve 
and muscle. 

The reaction of degeneration (RD), therefore, is closely connected 
wuth degenerative atrophy of the muscles. Thus it occurs — in poHo- 
myelitis acuta, chronica, spinal progressive muscular atrophy, amyo- 
trophic lateral sclerosis, lesions of a section of the gray anterior horns 
from hemorrhage, tumors, etc. ; bulbar paralysis ; in traumatic lesion 
of the peripheral nerves ; in neuritis of all kinds ; in " rheumatic " 
paralyses ; in primary multiple neuritis ; in toxic paralyses and those 
that occur after infectious diseases. 

The presence of RD points directly in opposition to disease within 
the sphere of the central neuron, therefore against cerebral paralysis, 
and to paralyses which result from lesion of the pyramidal tract in the 
spinal cord ; further, against myopathic paralysis ; lastly, against func- 
tional or hysterical paralysis. 

Of course, the RD is to be regarded as contraindicating the dis- 
eases last named only with the reservation that there is no complica- 
tion with the conditions first named. Of this character we, with 
others, consider also the condition of RD found by Schultze and Zim- 
merlin with myopathic progressive muscular atrophy [see previous 
page]. 

In harmony with the above principles, partial RD has exactly the 
same significance as complete. It occurs — i. In slight affections (as 
slight forms of rheumatic facial paralysis, slight paralysis of the arm 
from pressure). 2. In atrophic paralysis, which only affects a portion 
of the bundles of the muscular fibers, it is disseminated (especially 
frequent in spinal progressive muscular atrophy, amyotrophic lateral 
sclerosis, multiple neuritis), and hence as a mixed reaction} 

When RD is absent, sometimes it does not strictly show that there 
is no affection of the anterior horns or of the peripheral nerves ; that 
is to say, it does not do so if we have to do with a disseminated dis- 
ease (see Mixed Reaction). RD may be wanting when there is an 
existing peripheral paralysis if it is very slight (very slight pressure- 
paralysis of the N. radialis, which heals in three to four weeks). 

RD in muscles that are not paralyzed is seen by itself in lead- 
paralysis and traumatic paralyses. 

{b) Significance of Diminished Irritability. — Lessened excitability, 
especially of nerves, without RD occurs chiefly in myopathic mus- 

^ See above, p. 483. 



EXAMINATION OF THE NERVOUS SYSTEM. 485 

cular atrophy (dystrophia muse, Erb), in muscular atrophy from dis- 
ease of the joints, and in lesions of the spinal pyramidal tracts, espec- 
ially if recent and very severe. Moreover, it is observed with multiple 
neuritis, arsenic-paralysis, alcohol-paralysis, bulbar paralysis, amyo- 
trophic lateral sclerosis, etc., and here it is probably to be counted as 
mixed reaction. 

An intermitting general paralysis, which lasts say for twenty-four 
hours, with complete or almost complete loss of all electrical reaction, 
has been observed by Westphal. Its nature is very problematical. 

{c) Significance of Increased Irritability. — Increased excitability as 
manifested by early occurrence of CaSC and CaSTe, occurrence of 
AnOTe, is an extremely important sign of tetanus. Slight increase is 
observed in cerebral, spinal, recent neuritic paralyses, in progressive 
muscular atrophy of spinal origin (here a more considerable increase, 
and this in muscles that are still performing their function). 

The increase of galvanic excitability of the muscles with RD, as 
well as of the faradic and galvanic irritability of the muscles with 
myotonic reaction, does not belong here. 

For Myotonic Reaction, see above, page 483. 

5. Mechanical Excitability of Muscles and Nerves. 

1. Upon striking a muscle with a percussion hammer we see that 
a short contraction occurs, like a CaSC with a tolerably weak current. 
We find these contractions increased and usually quite decidedly slow 
in those muscles which show electrical RD — " mechanical RD." If 
distinctly present, this shows the same thing as the electrical RD ; but, 
often enough, it either fails or is not distinct, while the electrical exami- 
nation proves the existence of RD. 

Increased mechanical excitability with energetic but slowly declin- 
ing and prolonged contractions (to as much as thirty seconds, Erb) 
are peculiar to myotonia congenita [see page 483]. 

For those who are experienced mechanical excitability is not with- 
out its value as a preliminary starting-point. But it cannot be a sub- 
stitute for the electrical test. 

2. Idio-imiscidar contractions are transverse prominences which ap- 
pear locally at the spot where the muscle is struck — thus far, without 
any diagnostic significance. 

3. Mechanical excitability of the nerves (striking upon the trunk of 
the nerve at the point of electrical stimulation) has individual differ- 
ences. In many healthy persons mechanical irritation does not cause 
any contraction at all. The mechanical excitability of the nerves — but 
not of the muscles — is very much increased in tetanus. In this dis- 
ease, on percussing the nerves of the extremities and the facial nerve, 
we almost always see not only very strong contractions in the 
respective muscles, but in most cases even a quick, somewhat 
vigorous movement of passing the hand downward at the pos- 
terior part of the cheek, diagonally to the branches of the pes an- 
serinus, suffices to produce an effective, very short contraction of all 
the mimic muscles of that half of the face. This phenomenon, called 
the ** facial phenomenon," in combination with the other phenomena oi 



486 SPECIAL DIAGNOSIS. 

tetanus, has great significance ; by itself, however, it is not deci- 
sive, since it occasionally occurs also in other neuroses, especially in 
neurasthenia, and even in healthy persons of any age, particularly in 
children. 

4. Charcot has discovered that a peculiar form of over-excitability 
of the nerves and muscles is characteristic of the lethargic stage of 
Jiypnosis in very hysterical persons — pressure upon' the nerve or 
muscle causes contracture. 

We mention here, further, the peculiar and obscure phenomenon of 
paradoxical contractiojis (Westphal). In passive dorsal flexion of the 
foot there occurs a tetanic contraction of the tibialis anticus which lasts 
from a few seconds to several minutes ; the tendon of the muscle 
becomes prominent ; the foot, even when it is no longer held, remains 
dorsally flexed. It frequently occurs in connection with increased 
tendon reflex. 

6. Co=ordination and Ataxia. 

In all motions there is necessarily a more or less compHcated 
concurrent action of a number of muscles. For example, in order 
to seize anything with the hand, not only are a series of muscles of 
the arm, hand, and fingers moved, but at the same time, or a minimum 
of time before, the scapula, as a fixed point for the arm, must be 
steadied ; moreover, from the free attitude of the body, the shifting 
of the center of gravity brought about by the motion of the arm 
must be equalized by the contraction of the muscles of the trunk 
and legs, equilibrium must be maintained — a proceeding which, it is 
evident from what has just been said, cannot be sharply defined. 
Hence, in order that the hand may attain its object, and in order 
that it may attain it in the shortest way and with a steady motion, 
a very exactly defined number of muscles must contract at the 
right instant and with the finest adjustment of energy. This correct 
selection of muscles and their regulation as to time and gradation of 
activity are designated by the term co-ordination. Originally this is 
acquired by practice by means of conscious and unconscious direction 
of our motions ; and it is preserved by an oversight which is contin- 
ually becoming less conscious and more unconscious, and which all 
our motions acquire. 

Children at first, for all intentional movements, are ataxic in grasping 
things as well as in walking, etc. But also in later years co-ordination 
for new, hitherto untried movements must be acquired : the more 
complicated they are, the more practice they require. Learning to play 
on musical instruments, to handle fire-arms, etc. are examples of this. 
The acquired co-ordination in walking can be partly lost again by want 
of use of the legs and debilitation from long-continued severe sickness, 
as in typhoid fever. 

The processes for acquiring and for maintaining co-ordination are 
certainly very diversified. Co-ordination will be acquired by the cor- 
rections which will be suggested by sensible irritations of all kinds, 
caused by the motions that are made and conducted to the central 
organs : the eye sees, the ear (of the violinist, for example) hears the 
motion itself or its effects, then the sensibility of the skin and the 



EXAMINATION OF THE NERVOUS SYSTEM. 487 

whole totality of deep sensibility furnishes information, and the correc- 
tion depends upon the sense of power of the muscles, which gives 
unconscious information regarding the intensity of the work accom- 
plished each time by the muscle. In this acquisition of co-ordination 
the conscious will participates in many ways ; on the other hand, in 
maintaining co-ordination it recedes very extraordinarily, and gives 
place to an unconscious influence of the motions by centripetal in- 
fluences. But, if necessary, it may at any moment take hold, and even 
with an effect contrary to that intended, in that the unusual, acquired, 
hence now again, new agent of the regulation of the will disturbs the 
co-ordination, which went on successfully before unconsciously. A 
person says, " I will make it particularly beautiful," and just at that 
instant he becomes awkward. This happens not only with nervous 
and embarrassed people, but also with those who are very calm : under 
the control of the will they suddenly perform a motion which has long 
been automatically made. 

Now, there is scarcely any doubt as to the nature of the centripetal 
influences, but where and how they bring their influence to bear upon 
the motor tract is very far from being clear. Voluntary motions cer- 
tainly proceed to a certain extent from regulation derived from the 
cortex (where the complex motions, like those for speech, must exist), 
but certainly still other portions of the brain, which probably act as 
reflex centers, have an influence upon this regulation (thus especially 
the cerebellum for the motions of the trunk and legs); and, lastly, 
no doubt the gray anterior horns have a part in directing the continu- 
ity of motion : they preside over the tonus of the muscles, the antago- 
nizing tension constantly in action during activity ; they are the seat 
of tendon- and skin-reflexes. That all these things have an influence 
upon the continuity of motion cannot be doubted. But, likewise, there 
is no doubt that the various centripetal influences upon co-ordination 
to a very great extent may act vicariously for one another, so that 
when there is the loss of the conscious skin and muscular sensibility 
or in the disappearance of centripetal stimulation, they call forth the 
muscular tonus, the more attentive regulation of the cortical innerva- 
tion (with the assistance, for example, of the eyes) replaces the loss of 
constancy ; that, on the other hand — for instance, in the case of the 
blind — the exquisite superficial and deep sensibility, conscious as well 
as unconscious, must become prominent. But now, if co-ordination 
can no longer be maintained, then with its disturbance there occurs 
ataxia. It is clear from the foregoing that ataxia may exist at the 
same time with perfectly normal vigor ; indeed, it has nothing whatever 
to do with native strength. 

Ataxia shows itself according to its degree only with delicate, or it 
may even w^ith gross, actions. It usually occurs as an excess of 
innervation in the sense of directing motion or as a want of restraint 
(tabes) — swing of the legs in walking, putting the feet down as if stamp- 
ing, or only a clumsy way of moving the feet when turning around (in 
closing the door of the consulting-room) ; thus, on account of the un- 
certainty, the legs are spread out in standing and walking ; impossibility 
of describing a circle with the foot when lying in bed, inability to ex- 
actly place the heel upon the knee of the other leg ; when endeavoring 



488 SPECIAL DIAGNOSIS. 

to take hold of anything, the hand misses it, as in the effort to take 
hold of one's own nose, in executing with the hand the finer move- 
ments of all kinds. In other kinds of ataxia there are other kinds of 
uncertainty, without this character of missing the mark, or the ataxia 
of the legs and trunk manifests itself by reeling. The control of the 
eyes sometimes diminishes the ataxia, sometimes not ; the first is often 
the case in tabes. Most ataxic patients accordingly show a noticeable 
inward consciousness with every, no matter how, ordinary voluntary 
motion (as walking), quite in contrast with persons in health [see Mtis- 
citlar Sense, page /]/|/|/"] 

Ataxia occurs — {ci) In cerebral affections, and particularly those of 
the cortex ; here with paresis, confined to a limb or one-half of the 
body ; with lesions of the vermiform process of the cerebellum, of the 
crura cerebelli, and of the pons and the corpora quadrigemina ; and, 
lastly, in individual cases in ordinary hemiplegia if there is shght spasm ; 
(h) especially in tabes, where ataxia is the most important symptom, 
sometimes after disease involving the whole thickness of the spinal cord ; 
{c) rarely, and generally to a slight degree, in diffuse peripheral neuri- 
tides ; (i) rarely as a highly-developed disturbance, though very fre- 
quently ataxia is distinctly recognizable in some persons after long 
confinement to the bed and especially after acute infectious diseases. 
Co-ordination is here temporarily and only partly lost. 

7. Spasms of the Voluntary Muscles. 

We combine under this designation all those pathological motions 
existing outside of the influence of the will; so we must go very much 
beyond the popular' literal idea of "spasms." But this cannot very 
well be avoided unless we purposely wish to divide the subject very 
minutely. First, then, a few general remarks : 

Tonic spasms are those lasting some time — from minutes to days 
and weeks — and are symmetrical. Clonic spasms, on the contrary, are 
contractions of short duration, followed by relaxation of the affected 
muscles. All, with the exception of some forms of trembling, exhibit 
phenomena of irritation derived from the nervous system, and, in fact, 
chiefly from the cortex, pyramidal tracts, the anterior horns of the spinal 
cord ; some probably also from the peripheral nerves (also from the 
muscles themselves — paralysis agitans, contractions of fibrillae). The 
pathological irritation is probably generally a direct one, but certainly 
also partly reflex ; and, indeed, there is no doubt that the same kind of 
spasm may be caused by direct as well as reflex influences — as partial 
traumatic and reflex epilepsy. Many kinds of spasm consist of motions 
that are always similar — many combined from a few and sometimes 
from a great many. 

Spasms are partly the intrinsic element of the given disease, the 
thing of which the disease consists ; partly they are a symptom ; and 
then, again, they may be a local sign or local symptom ; that is, they 
may point directly to the seat or point of origin of the disease. Often 
we must determine other phenomena (as paralysis, etc.) for the purpose 
of discovering the point of origin. 

With certain spasms, especially those that are paroxysmal and 



EXAMINATION OF THE NERVOUS SYSTEM. 489 

general, the condition of self-consciousness at the time of the attack 
is of great diagnostic importance. Also we often have to consider the 
general mental condition, for many cases of convulsions lead us over 
into the territory of psychiatria. 

We now only mention the different kinds of spasm : 

Trembling (tremor) consists of unproductive motions, often only to 
be seen by close observation, rapidly following one another. We 
recognize them partly by observing the limb when at rest, partly when 
the hand is extended, or is holding a glass of water, and also by the 
handvvTiting. 

Graphic representation shows that the different forms of tremor 
differ in the form, frequency, and rhythm of the contractions. Trem- 
bling is physiological with bodily exertion and with mental excitement, 
and it is sometimes constant, even with persons in good health. Upon 
the borders of the normal stand the tremors of the aged, tremor senilis. 
Alcoholic tremor, especially of the extremities and tongue, occurs with 
the passing away of the effects of the indulgence, or when it is declin- 
ing ; the tremor satiirniiuis, the tremor which affects morphia-habitues 
when they abstain from it, that with morbus Basedowii (generally very 
fine, rapid movements, sometimes also coarser contractions), and the 
tremors of nervous individuals, are the finer kinds of tremors. 

The tremor of paralysis agitans (especially of the extremities, but 
also of the head) manifests itself by a symmetrical rhythm, by a very 
characteristic position of the hand and fingers ("pill-maker"). It 
ceases when voluntaiy motions are made, especially if vigorous, but 
sometimes even when writing. 

On the other hand, the intention tremor occurs only with voluntary 
motions, in that toward the end of the motion it becomes stronger ; it 
stops as soon as the patient is quiet. It is an important symptom of 
multiple sclerosis ; it occurs, however, as tremor merciirialis. In many 
cases it is difficult to distinguish it from ataxia.^ 

Between "tremor" and " clonic spasms " it is not possible to draw 
a precise distinction. The designation shaking-spasm is used for the 
transition forms of both. The prominent transition forms of this kind 
of tremor are those shiverings which begin with fine tremors, becoming 
constant!}' coarser with cooling off, and with rapidly-rising fever; 
with hysteria there are conditions that resemble tremor. Likewise is 
to be mentioned the quaking which occurs with marked active spasm 
of the legs, as especially takes place sometimes after mechanical irri- 
tation ; foot-clonus, particularly, often shows these transition forms 
very beautifully. 

In the foreg-oincr we have not distino-uished between the tremors of 
spasm and those of paralysis, because in regard to most kinds of 
tremors it is not yet clear to which of the two classes they belong.^ 

Tibrillary Contractions. — These are contractions in individual coarse 
or fine bundles of muscular fibers which ordinarily do not produce 
motion in the limb ; only in individual cases, however, we can observe 
a very diminutive motor effect. They are easily recognized by observ- 
ing the muscle. In health they are often excited (with great individual 
differences) by the cooling of the skin ; but they also occur with. 

^ See above. ^ Regarding this, see the several special works. 



490 SPECIAL DIAGNOSIS. 

atrophic paralysis, and very abundantly, and hence are not without 
diagnostic value, in spinal progressive muscular atrophy. 

Clonic spasms rarely occur by themselves, but they more frequently 
accompany epileptic and other attacks of convulsions.^ We sometimes 
observe them isolated in local affections of the cortex of the brain ; ^ 
but also in other localized cerebral diseases, and in myelitis transversa, 
as single brusque bending motions of the legs, generally both legs 
together — probably of reflex origin. 

Tonic spasms, by themselves, occur most frequently in the form of 
active spasms,^ in lesions of the pyramidal tracts, and with hysteria. 
Moreover, they occur in tetanus, and in these forms : as masseter 
spasms in trismus (this latter also by itself) ; as rigidity of the face, 
risus sardoiiicus ; extension of the vertebrae: rigidity of the neck and 
opisthotonos , d.nd in spasms of the legs in the state of extension. More- 
over, tonic spasm of the muscles occurs when first moving them after 
long rest, and as a prolonged condition after voluntary contractions 
in myotonia congenita; also, occasionally, as bending and adduction 
spasms of the arm and hands in tetanus ; as the tonic form of zvritei's' 
cramp, although seldom purely as such, generally with slight contrac- 
tions mixed with tremor; and in the first stage of epileptic attacks 
(see below). 

Epilepsy. — In genuine epilepsy, generally though not always the 
convulsions pursue a typical course : after certain subjective warnings 
{aura), or without these, there is a sudden loss of consciousness, ush- 
ered in with a cry, and immediately the patient falls. Then there is 
a short tonic spasm of all of the voluntary muscles (more especially 
of the extensors of the arms, legs, vertebrae, but the hands are closed 
and the thumb is grasped by the fingers); then there is clonic spasm, 
with great vigor of all the muscles of the body, including the mus- 
cles of the eyes, tongue, etc. ; after a few minutes there follows, either 
gradually or suddenly, a period of relaxation with continued loss of 
consciousness — post-epileptic coma. During the attack the tongue is 
often bitten, involuntary discharges take place, and, from the interfer- 
ence with respiration, marked cyanosis often occurs. 

It is very important to make a differential diagnosis between genuine 
epilepsy and symptomatic convidsions, which often very much resemble 
the former. The latter occur in all manner of anatomical diseases of 
the brain (regarding partial epilepsy in disease of the cortex of the 
brain, see below), as traumatic and reflex epilepsy, as epileptiform 
spasms in uremia, these latter also as eclampsia gravidarum. 

There occur in children, upon slight provocation, epileptiform or 
eclamptic attacks during dentition, from intestinal irritation from worms, 
in the beginning of acute infectious diseases, as scarlet fever, measles, 
pneumonia, and in the beginning stage of acute poliomyelitis and en- 
cephalitis. 

It is generally very difficult to form an opinion regarding spasms 
from the anamnesis. Here we must be very cautious in arriving at a 
diagnosis. 

Partial or Jackson's Epilepsy, Dissociated Spasms. — In this there are 
epileptiform convulsions which are limited to an extremity or to the 

^ See below. ^ See below, Partial Epilepsy. ^ See above, p. 456. 



EXAMINATION OF THE NERVOUS SYSTEM. 491 

facial muscles of one side. They are an almost infallible sign of disease 
located in a corresponding part of the cortex of the brain, and also are 
accompanied or followed by paresis, increased tendon-reflex, and some- 
times by disturbance of the sensibility of the affected limb {inoiwplegici). 
The convulsions may be unilateral or even general, but they always 
manifest themselves as originally partial-epileptic by beginning in the 
affected limb, recently designated by many as the one " primarily 
having spasms." 

Hysterical convulsions (attacks of hystero-epilepsy) sometimes have 
a great likeness to epilepsy, yet almost always the motions may be 
distinguished in that they are more wide-reaching [and tumultuous], 
and more than all by the fact that they partly manifest co-ordinated 
motions or remind one of them. Motions such as we see made by a 
person senselessly furious or an unruly child are not at all infrequent ; 
especial manifestations are fits of laughing, shouting, weeping, coughing. 

The most important mark of difference between hysterical and epi- 
leptic spasms in doubtful cases is that in the former there is almost never 
an entire loss of consciousness ; very often it remains quite intact ; and 
the absence of involuntary discharges (urine, stool, in males also of 
semen), as is not infrequent with genuine epilepsy ; lastly, the tongue 
is not bitten and there is reaction of the pupil during the attack. 

Gross [Severe] Hysteria. — The attack of hystero-epilepsy may pass 
into a second stage [" phase des grand mouvements " of the French] 
of contortions and excessive movements — among others, especially 
that of the " arc de cercle " (head bent backward, boring into the pil- 
low ; the trunk bent as in opisthotonos), which may last for hours, is a 
characteristic manifestation ; then there may follow a third stage, which 
is either quiet or may be excited (delirium) — the stage of hallucinations 
and of emotional attitudes. The stages may occur singly. 

Besides what has already been described, it is important for diag- 
nosis that the patient should manifest hysterical sigJis (stigmates hys- 
teriques) in the form of sensory anesthesia, especially a concentric 
limitation of the field of vision ; also, hemianesthesia ; lastly, hysterog- 
enous zones ; that is, hyperesthetic regions of the body (ovaries, tes- 
ticles, circumscribed portions of the skin), the irritation of which by 
pressure sometimes causes an attack or is associated with one. 

Constrained Positions and Motions. — To the former belong draw- 
ing of the head or trunk to one side, so that the patient assumes the 
side position in bed (sometimes with the eyes fixed ; deviation conjugee 
occurs with the other manifestations) ; to the latter belong the involun- 
tary forward, backward, and movement in a circle (manegegang). Both 
phenomena indicate a lesion of the vermiform process of the cerebellum 
or of the median crus cerebri. 

With the constrained motions or " co-ordinated spasms " are also 
to be reckoned the gross motions previously mentioned under hysteria, 
as laughing, screaming, etc. 

Chorea Minor. — This is the designation given to the very rapid, 
lightning-Hke, entirely irregular muscular contractions, which, on the 
one hand, produce restlessness of the limbs and of the face, and, on the 
other, divert the regular voluntary motions. They affect the head (face, 
tongue, masticating muscles), the muscles of the trunk, especially of 



492 SPECIAL DIAGNOSIS. 

the shoulders and legs, and sometimes the glottis. They occur in all 
degrees of severity, from single weak jerks to the most extravagantly 
confused strong movements (folic musculaire). If the subject is em- 
barrassed, especially if observed, frequently the contractions are in- 
creased. During sleep, but there may be difficulty in getting to sleep, 
the convulsions entirely disappear, excepting in particularly severe 
cases. 

Chorea minor is not often purely one-sided : lieinichorea. Hemi- 
chorea may occur either as the forerunner or as the result of hemiplegia 
when it indicates a lesion of the posterior section of the inner capsule 
or of the optic thalamus. Especially frequent are choreic or athetose 
motions ^ in the paralyzed limbs, with declining acute encephalitis in 
children (polio-encephalitis — Striimpell). Quite recently Flechsig has 
found both internal segments of the lenticular nucleus diseased in sev- 
eral cases of severe general chorea Avith delirium. 

Athetosis [described by W. A. Hammond]. — This designates pecu- 
liar, slow, and at the same time tolerably energetic motions, particularly 
of the hands, arms, shoulders, but also anywhere else. If the motions 
are somewhat quicker than, but resembling, those of chorea, they then 
form a transition to the latter. Athetosis, as well as chorea, is a disease 
in itself; hemiathetosis is observed in the same cerebral locations as 
hemichorea (which see). In the cerebral paralyses of children it is 
more frequent than hemichorea. 

Associated movements are abnormal involuntary motions which 
take place, with the performance of voluntary motions, by contraction 
of muscles in regions which have nothing to do with the motions 
desired. We find them especially in cerebral, but also in spinal and 
even in peripheral, paralyses ; hence they cannot be made use of as an aid 
in diagnosis. Sometimes we see them in the muscles of the limb which 
is being put in motion. Particularly frequent is a dorsal flexion of the 
foot when the leg is drawn up to the abdomen, as in hemiplegia, spastic 
spinal paralysis (Striimpell), or in the unilateral affections as synony- 
mous associated movements of the sound side with those of the diseased 
side or of the diseased side with the sound side. 

Catalepsy, cataleptic rigidity, flexibilitas cerea, is a peculiar increase 
of the tonus of the voluntary muscles of such a character that the limbs 
not only offer a very slight or feeble resistance in passive motion, but 
also remain in a given position, even when it is opposed to gravity, and 
this sometimes for an hour or more at a time. Catalepsy very rarely 
occurs in anatomical diseases, as tumors of the brain and meningitis ; 
more frequently in hysteria, especially in hypnosis, and in certain psy- 
choses, as melancholia attonita. 

8. Voluntary Muscles, their Innervation, their Function, and the 
Diseases that Disturb Them. 

1. Muscles of the eye (see Examination of the Eye). 

2. Muscles of the face, supplied by the N. facialis : 

M. frontalis draws up the brow and causes wrinkles across the 
forehead. 

^ See below. 



EXAMINATION OF THE NERVOUS SYSTEM. 493 

M. corrugator supercilii draws the skin of the forehead over the root 
of the nose into folds. 

M. orbicularis palpebrarum closes the eyes. 

M. depressor nasi seu dilator narium dilates the nostrils. 

M. levator labii superioris (proprius) and M. levator anguli oris lift 
up the upper lip and the corner of the mouth. 

M. zygomaticus major raises and draws out the angle of the mouth. 

M. buccinator makes the cheeks tense, holds open the pouch of the 
cheek when eating, prevents the distention of the cheeks when blowing 
or whistling (to a slight extent supplied by the trigeminus ?). 

M. orbicularis closes the mouth ; it is the chief factor in whistling, 
pronouncing the consonants b, f, in, p, v, zv, the vowels o, ii (greatly 
assisted by the levator menti). 

Paralysis of the Facial. — The forehead is smooth and remains so 
upon the affected side when the effort is made to wrinkle it ; the eye 
remains open and cannot be closed (lagophthalmus) ; the naso-labial 
furrow is obliterated ; the angle of the mouth hangs down ; the mouth, 
and often also the tip of the nose, are drawn toward the sound side ; 
the effort to expose the teeth, as in cleansing them, makes very 
plain the defective elevation of the upper lip and distortion of the 
mouth. When blowing, the affected cheek is distended ; on attempt- 
ing to whistle, the lips are drawn to the sound side ; if the paralysis is 
unilateral, the labials are generally, except in recent paralyses, pro- 
nounced distinctly ; if bilateral, they cannot be. See, further, Soft 
Palate, Hearing, Taste. 

Cerebral facial paralysis, from disease of the cortex, or in the course 
of the pyramidal tract, is usually distinguished from peripheral paralysis 
in' a remarkable way : in the first place, the former almost never affects 
the whole facial of one side, but leaves untouched, or nearly so, the 
forehead and ocular facial. This may possibly result from the fact that 
on both sides the muscles of the forehead and for closing the eye are 
innervated from both hemispheres, because they are usually active on 
both sides simultaneously ; furthermore, in cerebral facial paralysis the 
emotional innervation is generally preserved : the patient in vain tries 
to move the angle of the mouth on the paralyzed side when ordered to 
do so, and yet when laughing shows little or no difference between the 
two sides of the countenance. This is never the case in peripheral facial 
paralysis, for here, on the contrary, voluntary and emotional paralysis 
of course always go together. From this peculiarity of cerebral paral- 
ysis, however, it follows that the emotional facial tract in the brain is 
distinct from the voluntary. This assumption is confirmed by the addi- 
tional fact that cases occur in which there is purely emotional facial 
paralysis, without visible paresis in repose, and without volitional paral- 
ysis. The anatomical conditions in these cases indicate that the optic 
thalamus and fibers of the corona radiata which originate from it come 
into consideration for the emotional facial tract further downward in 
the tract of the cerebral peduncle and tegmentum. 

3. Muscles of Mastication, Tongue, Soft Palate, Pharynx. — Mm. tem- 
poralis and masseter (N. trigeminus branch III.) draw up the lower 
jaw and press the teeth together. Mm. pterygoidei effect the sideways 
movement (rotation) of the lower jaw. 



494 SPECIAL DIAGNOSIS. 

Paralysis of these muscles will be recognized by the absence, upon 
one or both sides, of these motions ; bilateral paralysis of the tempo- 
ralis and masseter, by the dropping of the lower jaw. Palpation 
below the zygoma detects possible paralysis and atrophy of the mas- 
seter ; above the zygoma, paralysis and atrophy of the temporalis is 
shown by its laxity. 

We pass over the complicated arrangement of muscles which draw 
down the lower jaw, because paralysis of these muscles has not yet 
been sufficiently studied. 

The tongue is protruded — that is, it is drawn forward by the two Mm. 
geniohyoglossi, which act somewhat convergently — and it is drawn 
back chiefly by the two Mm. styloglossi ; M. hypoglossus principally 
draws It down. These and the inner lingual muscles produce the 
changes in the form of the tongue. 

Unilateral Hypoglossal Paralysis. — When the tongue is protruded it 
deviates toward the paralyzed side, because the genioglossus of the 
sound side pushes it that way. Bilateral paralysis (generally atrophic) 
causes diminution of all the motions, even to their complete oblitera- 
tion, difficulty in mastication and swallowing and in the formation of 
the consonants c, d, g, k, /, ;/, r, s, sch, x, -S", and of the vowels i [^] e 
\d\. Unilateral paralysis produces all these disturbances to a slight 
degree, and they become less with habit. Atrophy, seldom unilateral, 
will be recognized by diminution in the volume, by wrinkles, and sen- 
sible thinness. 

The soft palate derives its principal innervation from the spheno- 
palatine ganglion (N. petrosus superficialis major), and from the ganglion 
geniculi of the facial nerve. The fifth and the tenth and eleventh gang- 
lia also take part. 

Examination. — By inspection and phonation — i. e. by observing the 
voice and inspection, and by the swallowing of fluids. 

Unilateral paralysis of the soft palate in paralysis of the facial located 
high up is manifested by deviation of the uvula toward the healthy side 
and depression of the arch of the paralyzed soft palate, both more 
distinctly in phonation. In the passive state the relaxed uvula may 
hang to one side, even when there is no paralysis. Sometimes the 
speech is nasal, and fluids may escape from the nose in attempting to 
swallow. Both symptoms are due to ineffectual closure between the 
nose and the mouth — pharyngeal space. In bilateral paralysis, espec- 
ially with bulbar paralysis and as diphtheritic paralysis, the soft palate 
hangs down without any power to contract, and nasal utterance and 
the difficulty in swallowing are increased. 

The pharyngeal muscles (Nn. X., XL), with the aid of the tongue, 
accomplish the act of swallowing. When they are palsied this act is 
disturbed, and, from the lack of vigor and promptness in passing the 
food along, food easily enters the larynx ; thus there is coughing in con- 
nection with swallowing. But if the patient is unconscious or at the 
same time there is disturbance of the sensibility of the larynx (N. laryn- 
geus superior vagi), there may be no cough. 

4. Laryngeal Muscles. — The muscles supplied by the laryngeus 
superior vagi are — depressors of the epiglottis ; Mm. thyreo-epiglottici, 
aryepiglottici (if paralyzed : difficulty in swallowing), and the M. crico- 



EXAMINATION OF THE NERVOUS SYSTEM. 495 

thyreoideus, tensors of the vocal cords by movement of the thyroid 
cartilage toward the cricoid cartilage (if paralyzed: hoarse voice). 

N. laryngeus inferior (recurrent branch of the N. X., XI.) : Mm. 
crico-arytaenoid. postici dilate the glottis (if there is bilateral paralysis : 
inspiratory dyspnea, sometimes of the severest kind, with the voice 
unchanged or very slightly impure). Mm. thyreo-arytaenoidei are 
the most important tensors of the vocal cords (if paralyzed : loss of 
voice and hoarseness). MuscuH arytaenoidei transversi et laterales : 
they narrow the posterior portion of the glottis. In isolated paralysis 
of the muscles the voice is very hoarse (as in catarrh, hysteria). Mm. 
crico-arytaenoidei laterales : in connection with the preceding they 
narrow the glottis. 

Complete paralysis of the recurrent : {a) unilateral (compression 
by aortic aneurysm, carcinoma of the esophagus, mediastinal tumors ; 
bulbar paralysis) : voice is hoarse, easily changing to the falsetto or 
little or even not at all altered ; (U) bilateral (rare) : there is com- 
plete aphonia, inability to cough. 

The laryngoscopic examination is indispensably necessary, regard- 
ing which see Appendix. 

5. Muscles of the Throat and Neck. — M. sterno-cleido-mastoideus (N. 
XI.) draws the head and face toward the opposite side and in the posi- 
tion of looking upward ; both together somewhat bend the neck and 
push the head forward ; or, if the head is the fixed point, they lift up 
the sternum or the clavicles, as in emphysema. The test of their func- 
tion and recognition of their paralysis and spasm are easy. When 
both are paralyzed, the neck, and with it the head, incline backward. 

The muscles that stretch, bend, twist the neck or the head (nervi- 
cervicales I.-IV.) maintain the head in the upright position. If they are 
weak or paralyzed it is impossible to hold the head up : it falls forward 
if it is not exactly balanced. This happens if the head is too heavy 
{hydrocephalus). Defective mobility of the head is more frequently 
caused by spasm or inflammation (stiff-neck, caries of the cervical ver- 
tebrae) than by paralysis. 

6. Muscles of the Trunk. — Muscles that move the vertebrae (inner- 
vated by Nn. dorsales and lumbales) : 

Lumbar extensors and extensors of the lower vertebra : M. erector 
trunci (sacro-lumbalis et longissimus) with bilateral action. 

Bending forward : the abdominal muscles. 

Bending of the lower vertebrae sideways : quadrati lumborum. 

Twisting the trunk : semispinalis and multifidus. 

Paralysis of the erector trwici : {a) Bilateral : the body is bent 
backward (lordosis of the lumbar, kyphosis of the upper thoracic, ver- 
tebrae, in such a way that the latter overhangs the sacrum ; a plumb- 
line held from it falls behind the sacrum) ; the pelvis is tilted up, the 
knees are bent. {8) Unilateral : in standing a scoliosis of the lower 
vertebrae is convex toward the diseased side ; on the other hand, there 
is a compensatory scoliosis of the thoracic vertebrae. 

Paralysis of the abdominal muscles : marked lordosis of the lumbar 
and lower thoracic vertebrae, compensatory kyphosis of the upper 
thoracic vertebrae, but these are exactly vertical over the sacrum. 
There is marked inclination of the pelvis. 



496 SPECIAL DIAGNOSIS. 

In paralysis of the extensors it is impossible to place the bent trunk 
in an unsupported upright position ; it is accomplished by placing the 
hands upon the knees and thighs. If, in addition, there is paralysis of 
the glutei, especially of the gluteus maximus, then the patient can only 
rise from the floor by first getting down on " all fours," then pushing 
himself up with the hands from the floor, in order immediately to put 
them upon the knees and thus further support the body : this is his 
only way of standing up. In paralysis of the flexors it is impossible 
to change from the dorsal to the sitting position without assistance. 

Opisthotonos is produced by spasm of the extensors, emprosthotonos 
by spasm of the flexors ; unilateral spasm of the extensors causes 
scoliosis, convex toward the diseased side. 

7. Muscles of the Thorax, Diaphragm, and Abdomen. — Here belongs 
most of what has already been said upon page 72, ff. There we learn 
regarding the ordinary and the auxiliary muscles of inspiration and 
the auxiliary muscles of expiration. 

Paralysis of the diaphragm (phrenic nerve, chiefly from the fourth 
nerve of the [deep] cervical plexus) in perfect quiet may be entirely 
compensated by the thoracic muscles of inspiration, but otherwise every 
increased requirement for breath produces marked dyspnea ; and this 
is exactly the case with respect to the vicarious action of the diaphragm 
when there is defective thoracic breathing. It will be understood, then, 
that paralysis of the auxiliary muscles of respiration has only a bad 
outlook for the breathing when it comes to such a pass that they must 
be called upon (see page 73). 

Tonic and clonic spasms of the thoracic muscles of inspiration in 
tetanus and epilepsy at once cause severe cyanosis ; in the first disease 
it may be fatal ; also tonic spasm of the diaphragm interferes very 
much with breathing and may be dangerous to life. Clonic spasm of 
the diaphragm (singidtus, hiccough) in a mild form is not infrequently 
seen ; if it continues for hours and days, as it sometimes does in 
abdominal and cerebral aflections, then from the disturbance of rest 
and severe pain along the line of insertion of the diaphragm it may 
bring about a serious condition. 

By the contraction of the abdominal muscles the anterior abdominal 
wall is flattened, and thus the abdominal cavity is lessened ; by the 
simultaneous contraction of the diaphragm there arises ''the abdominal 
pressure," which is important in defecation, urination, and expulsion of 
the child in labor. The role of the rectus and obliquus externus as 
flexors of the vertebral column (when those of one side act alone the 
trunk is bent laterally forward over to one side) has been already 
mentioned, as well as their function in active expiration. 

8. Muscles of the Upper Extremity. — [a) Muscles which move the 
shoulder-blade or fix it : 

M. trapezius (N. accessorius for the most part) raises the shoulder- 
blade and draws it toward the middle line, both of these movements by 
its middle and posterior parts. The former chiefly lifts the acromion, 
the latter the inner upper angle. With its anterior clavicular portion 
it inclines the head obliquely backward and at the same time lifts 
the acromion. Paralysis of the trapezius permits the scapula to drop, 
to be drawn away from the middle line, and at the same time to 



EXAMINATION OF THE NERVOUS SYSTEM. 497 

turn round so that its apex moves toward the spinal column (because 
the levator scapulae holds up the upper inner angle). The shoulder 
sinks downward and forward ; there is difficulty in raising the upper 
arm, because the scapula is not so perfectly fixed, and shrugging of the 
shoulders is restricted. From what has been said the test of its func- 
tion is easy. 

M. levator anguli scapulae (N. dorsaHs scapulae from the cervical 
plexus and branches of this plexus) lifts the scapula by its inner 
upper border, with the tendency to turn the right scapula in the direc- 
tion of the hands of the clock and the left in the opposite direction. 
Its paralysis can only be recognized, when the trapezius is paralyzed 
at the same time, by the complete inability to lift the shoulder. 

Mm. rhomboideus major et minor (N. dorsaHs scapulae) draw the 
shoulder-blades toward the spinal column, and thus lift them in the 
same way as the levator scapulae, and turn them in such a way that 
the lower angle of the scapula is nearest the spinal column. They 
fix the scapulae, especially in backward motions of the arms and legs 
and when lifting weights. Paralysis [of these muscles] causes the 
scapula, and particularly its lower angle, to move away from the spinal 
column. Moreover, it is difficult to detect paralysis of these muscles 
when the trapezii are normal. 

M. serratus anticus (N. thoracicus longus seu posterior (Henle), 
from the brachial plexus) turns the scapula in such a way that the 
lower angle moves outward, draws it somewhat away from the spinal 
column, and presses it against the thorax : it is an important fixation- 
muscle of the scapula when the arms are lifted. When the scapula is 
fixed (by the rhomboidei) it is a muscle of inspiration. Paralysis of 
the serratus, in the condition of rest, causes a slight elevation and rota- 
tion of the scapula, so that the lower angle stands out a little from the 
thorax and is slightly drawn toward the spinal column. The arm can 
be lifted to the horizontal sideways : this moves the inner border 
of the scapula close up to the vertebral column. It can only be raised 
higher by fixing the scapula in the same way as would be accomplished 
by the serratus. When the arm is moved forward the inner border of 
the scapula stands out like a wing. 

il)) Muscles of the trunk and of the scapula [attached] to the upper 
arm : 

M, deltoides (N. axillaris at the infraclavicular portion of the 
brachial plexus) : the middle portion extends the arm outward from 
the body, the anterior portion raises it obliquely forward, the posterior 
portion obliquely backward. It raises it as far as the horizontal, 
beyond which, the arm being fixed by the deltoid against the scapula, 
it is raised by the rotation of the scapula. Paralysis is easily recog- 
nized : if the muscle is relaxed, there is subluxation of the humerus, 
particularly if at the same time the supraspinatus is paralyzed ; if the 
deltoid is atrophied, the contour of the bones at the shoulder shows 
plainly. 

M. supraspinatus (N. suprascapularis from the supraclavicular por- 
tion of the brachial plexus) assists the deltoid in raising the arm out- 
ward toward the front, and rolls it inward ; it is also said to hold the 
head of the humerus in its socket when the arm is raised. 

32 



49^ SPECIAL DIAGNOSIS. 

Mm. infraspinatus (N. suprascapularis) and the teres minor (N. 
axillaris) roll the upper arm outward. 

M. subscapularis (N. subscapularis from the brachial plexus) is a 
rotator inward. Paralysis of a rotator allows the arm to rotate in the 
opposite course ; in testing, we first make passive rotation, and, letting- 
the arm fall, allow it actively to do the same thing while we oppose 
the rotation. 

M. pectoraHs major (Nn. thoracici anteriores of the brachial plexus) 
adducts the upper arm ; when the arm is raised it moves it forward 
in the horizontal plane, draws the arm down when it is raised. Test : 
Have the upraised arm moved forward in a horizontal plane while we 
offer resistance. 

M. latissimus dorsi (N. thoracico-dorsalis from the brachial plexus) 
draws down the arm when it is raised in exertion [it depresses it] ; 
and draws it backward. When the arm hangs down it draws it back- 
ward and inward [toward the buttock]. Test: The arm is raised to 
the horizontal, and the effort is made to lower it while the movement 
is opposed. The teres major materially assists the latissimus; it is at 
the same time a rotator inward. 

Mm. coraco-brachialis (N. musculo-cutaneus of the median) and 
anconeus longus (caput longum tricipitis ; N. radialis), when the arm is 
drawn down by the latissimus and pectoralis, hold the head of the 
humerus up and firmly in its socket. 

{c) Muscles from the upper arm to the forearm : 

M. triceps (N. radiaHs) is an extensor of the forearm. 

M. brachialis internus (N. musculo-cutaneus) is a simple flexor. 

M. biceps (N. musculo-cutaneus) flexes and supinates. 

M. supinator longus (N. radialis) flexes and pronates. This is 
proved by having the moderately pronated forearm flexed while the 
movement is resisted. If it is healthy, it rises Hke a hard roll on 
the outer side of the elbow-joint. 

We here next mention the pronators : the pronator teres (it is at 
the same time a flexor) and quadratus, both supplied by the median 
nerve. 

{d) Muscles which extend from the condyles of the humerus and 
the bones of the forearm to the hand and fingers, and the small mus- 
cles of the hand : 

The extensor carpi radialis longus and brevis (N. rad.) + extensor 
carpi ulnar. (N. rad.) are elevators of the hand. The flexor carpi 
radialis (N. median) + flexor carpi ulnaris (N. ulnar.) are volar flexors 
of the hand ; the palmaris longus (N. median) assists in this action. 

The extensor carpi radialis longus + flexor carpi radialis adduct the 
hand in the direction of the radius. Extensor carpi ulnaris -f flexor 
carpi ulnaris adduct the hand on the ulnar side. If the extensor carpi 
radialis longus acts alone, it raises the hand obliquely on the radial side, 
as the extensor carpi ulnaris does on the ulnar side. 

Paralysis of the extensors of the hand (especially lead-paralysis, 
also sleep-paralysis of the N. radialis) allows the hand, when the fore- 
arm is pronated, to hang loosely. Paralysis of the abductors and 
adductors, and also paralysis of the extensores carpi radialis longus 
and carpi ulnaris alone, produce oblique position of the hand [paralysis 



EXAMINATION OF THE NERVOUS SYSTEM. 499 

from the former giving a position opposite to that of the latter]. We 
test the individual movements by successively opposing them. 

M. extensor digitorum (communis, indicator, extensor digiti V., all 
from the N. radial) extend the first phalanges. 

M. flexor digitor. comm. sublim. (N. median) flexes the middle 
phalanges ; M. flexor digitor. comm. prof (N. median, the two ulnar 
beUies from N. ulnaris) flexes the terminal phalanges. Mm. interossei 
dorsales + volares (N. ulnaris) and Mm. lumbricales (N. median and 
ulnaris) flex the first phalanx, and at the same time extend the middle 
and terminal phalanges. 

Mm. interossei dorsales alone abduct (spread apart) the fingers, 
volares alone adduct the (middle, third) finger. 

Movements of the thumb : extensor poUicis longus (N. rad.) is essen- 
tially an extensor of both phalanges ; extensor poUicis brevis (N. rad.) 
is an extensor only of the first phalanx. Adductor poUicis longus 
(N. rad.) abducts the metacarpus. Flexor pollicis longus (N. med.) 
flexes the terminal phalanx. At the thenar are the opposing muscles — 
abductor pollicis brevis, outer head of the flexor brevis, and the oppo- 
nens poUicis (all from the N. med.). Adductors : adductor pollicis and 
the inner deep head of the flexor brevis (both N. ulnar.). These two 
and the abductor brevis flex the first and extend the terminal phalanx. 

The adductor, flexor, and opponens act at the hypothenar, their 
names indicating their action. All are innervated by the N. ulnaris. 

Oiaracteristic positions of the hand and fingers : i . In paralysis of 
the ulnar there is the clawing, clutching hand — main en griff e : the 
first phalanges are extended, the middle and terminal ones flexed 
(paralysis of the interossei), the thumb hangs helpless over the hand 
(paralysis of the adductor), the fingers are easily spread apart (action of 
the extensores digitorum). Thus the interosseal spaces on the dorsum 
are deepened, likewise the groove between L and II. metacarpal bones 
(atrophy of the adductor pollicis, deep head of the flexor brevis and 
interosseous dorsi I.). The hypothenar is atrophic. 2. In paralysis 
of the thenar (deep median paralysis) there is the ape-hand : the 
thumb does not stand out opposing, but is parallel with, the other 
fingers. 

Paralysis of the extensors of tlie Jiand causes apparent weakness of 
the long flexors of the fingers because the origin and insertion of the 
flexors are brought near together by the flexion of the hand at the 
wrist. Hence we must passively extend the wrist and then test the 
flexion of the fingers. For the same reason it is necessary, when there 
is paralysis of tlie long extensors of the fingers, to passively extend the 
first phalanx before testing the flexion of the middle and terminal 
phalanges. 

Examination. — We observe the position of the hand for possible 
atrophy. Then we test extension, flexion, abduction, and adduction 
at the wrist — sometimes all of these — by resisting these motions ; then 
the extension of the fingers ; next the long flexors by " hooking " of 
the fingers ; then let the patient make the separate motions of the 
interossei muscles ; flex the first phalanx with the middle and end 
phalanges extended ; then spread apart and close the fingers ; test the 
muscles of the thenar and hypothenar by bringing the thumb and little 



500 SPECIAL DIAGNOSIS. 

finger into contact ; lastly, the examiner places his own index finger 
in the saddle between the thumb and the second metacarpus, while 
the patient makes simple adduction of the thumb, thus testing the power 
that is manifested. Pressure of the hand is a very practical way of mak- 
ing a general test of the long flexors and the small muscles of the hand. 
For such paralyses as are not wholly diffuse, but rather confined to 
individual muscles or groups of muscles (peripheral and certain spinal 
paralyses), it has value only as a preliminary examination. For various 
reasons we consider the dynamometer as an unnecessary apparatus and 
one that does not accomplish its purpose. The instrument which 
relatively is most useful is that of Ullmann of Zurich. 

It cannot be sufficiently insisted upon that in order to establish the 
diagnosis exactly in the upper extremity, and particularly in the hand, 
besides a clear conception regarding the location and physiological 
action of the muscles, there must be a knowledge of their innervation. 
We observe, especially, how the ulnar and median are distributed in 
the small muscles of the hand. The former innervates the hypothenar 
interossei, the two ulnar lumbricales, and the adductors of the thenar : 
adductor poUicis, and the deep head of the flexor brevis ; the latter, 
the remaining muscles. In the hand the radial only supplies branches 
to the skin. 

9. Muscles of the Lower Extremity. — {a) Muscles from the pelvis to 
the thigh. 

M. ileo-psoas (N. crural is from the lumbar plexus) flexes the hip- 
joint; it is assisted (and in the sense of pure flexion) by the action of 
tensor fasciae latae (N. gluteus superior from ischiadic plexus). In 
paralysis of the psoas or of this and the tensor fasciae it is not possible 
to flex the thigh either in walking or in bed ; paralysis of the tensor 
fasciae alone permits the pure psoas action to take place — flexion with 
rotation outward. 

M. gluteus maximus (N. gluteus inferior or plexus ischiadicus) extends 
the thigh ; when the thigh is fixed it brings the pelvis to the horizontal 
position, and thus the trunk to the vertical (into the upright from the 
stooping posture, standing upright, etc.). When it is paralyzed there 
is the peculiar kind of action in rising from the floor described on page 
496, with paralysis of the extensors of the trunk. 

M. gluteus medius (N. gluteus superior from the plexus ischiad- 
icus), abductor ; M. gluteus minimus (same nerve) rotates the thigh 
inward. The three glutei are the most important supporters of the 
pelvis. 

M. pyriformis (plexus ischiadicus), M. obturator internus (N. ischiad- 
icus), M. gemelli (N. ischiadicus), M. obturator externus (N. obturatorius, 
plexus lumbalis), M. quadratus femoris (N. ischiadicus) are all, in reality, 
out-rotators. 

M. adductor longus, brevis, magnus, pectineus and gracilis (N. ob- 
turatorius, plexus lumbalis) are, for the most part, adductors, at the 
same time partly flexors. The effect of their paralysis is clear. 

[F) Muscles from the pelvis and the femur to the leg : 

M. quadriceps (N. cruralis) extends the leg ; its long head, the rec- 
tus, arises from the pelvis (anterior inferior spine), and hence acts with 
more power when the thigh is in a position of extension with reference 



EXAMINATION OF THE NERVOUS SYSTEM. 50I 

to the pelvis. In paresis of the quadriceps the leg (or possibly both 
legs) in walking is frequently set forward, flexed more markedly at 
the knee-joint (the leg during the forward movement of the limb hangs 
vertically down); and this is true also when it is set down quickly, so 
that there is a sort of snapping of the knee-joint into the position of 
extension. The examination is best made by endeavoring to flex the 
limb when it is actively extended. 

M. sartorius (N. cruralis) is probably chiefly an inward rotator of the 
flexed leg. 

Mm, biceps femoris, semitendinosus and semimembranosus (N. 
ischiad.) flex the knee-joint ; the first rotates the flexed leg outward, the 
second inward. If the limb is powerfully extended by the quadriceps, 
then these flexors, as well as the gluteus maximus, act : they place the 
pelvis in the horizontal position (important in walking). 

(r) Muscles from the leg (or the condyles of the femur) to the foot 
and toes : 

M. gastrocnemius, soleus, plantaris (N. tibial.) are extensors ; that 
is, are plantar flexors of the foot, and, at the same time, adductors of 
the extended foot. 

Mm. peroneus longus and brevis (N. peroneus) are extensors (chiefly 
the first) and adductors of the foot, lift the outer border of the foot. 
In paralysis of the peronei muscles (by " peroneus-paralysis " we mean 
paralysis of the whole peroneus nerve : see below, under M. tibialis 
anticus) : the foot in extension, as well as flexion, stands in the position 
of adduction and the outer border of the foot is deeper ; the foot be- 
comes flat. It is not easy to test the activity of the peronei : we must 
first show the patient the movements of abducting and lifting the 
outer border of the foot by passive movements, and then have him re- 
peat them ; besides, we have the patient extend the foot : in paralysis 
of the peroneus longus decided adduction then takes place. 

M. tibialis anticus (N. peroneus) flexes — that is, dorsally flexes and 
adducts — the foot; Mm. extensor digitorum communis and extensor 
hallucis longus (N. peron.) flex and adduct the foot and extend the toes. 
Paralysis of the dorsal flexors causes the point of the foot to drop 
when the foot is lifted from the floor. If the peronei are likewise paral- 
yzed (peroneal paralysis ; that is, paralysis of the peroneus nerve), then 
the foot is lax at the ankle-joint ; the point of the foot hangs down, 
with inclination to adduction. In walking we observe that the foot, 
as it is raised from the floor, makes a peculiar shuffling motion inward, 
and it is set down in a fumbling manner. Persons with unilateral, iso- 
lated peroneal paralysis are always inclined to take a longer step with 
the disabled limb in order to obtain the sweeping motion required for 
the awkward placing of the foot upon the floor. 

M. tibialis posticus (N. tibial.) is an adductor. 

Mm. flexor digitorum communis longus and brevis (N. tibial.) are 
flexors of the middle and terminal phalanges of the toes ; Mm. inter- 
ossei externi + interni (N. tib.) are flexors of the first, extensors of the 
middle and terminal phalanges — interossei externi. [The outer three 
muscles are abductors of the second, third, and fourth toes respectively, 
while the first is an adductor of the second toe and assists the plantar 
interossei.] 



502 SPECIAL DIAGNOSIS. 

Paralysis of the interossei causes a peculiar kind of claw-position 
exactly analogous to that of the fingers.^ 

M. extensor hallucis longus (N. peron.) extends the first phalanx of 
the great toe ; Mm. adductor, flexor brevis, abductor hallucis (N. tib.) 
act essentially in accordance with their names : they produce simulta- 
neously flexion of the first and extension of the terminal phalanx. 
Paralysis of the flexor of the great toe hinders one in walking, but 
especially in springing. 

DISTURBANCES OF SPEECH (LALOPATHY). 

I. Dysarthria and Anarthria. 

By these expressions we understand those disturbances of speech in 
which we see it altered in the same way as the activity of a joint is dis- 
tributed as to its motility — by paresis, paralysis, trembling, spasm, and 
even ataxia of the vocal muscles. 

Unilateral paralysis of the muscles of speech occurs in unilateral 
affections of the pyramidal tract above the medulla oblongata or of the 
cortical center of the motor-speech muscles ; likewise in peripheral 
paralysis of the hypoglossus and facial nerves. At first the speech is 
decidedly disturbed ; if these affections continue, there occurs a con- 
siderable improvement in the speech, as if it were reacquired by prac- 
tice. Bilateral paralyses generally occur from the bulbus of the oblon- 
gata (bulbar paralysis), and are then, if due to diseases of the motor 
nuclei, degenerative-atrophic. It is rare to have bilateral speech- 
paralysis from bilateral cortical or pyramidal lesion (pseudo-bulbar 
paralysis). We also rarely have a bilateral paralysis of peripheral 
origin of the hypoglossus or facial nerve. 

For the muscles that produce speech and their innervation see pages 
494 and 495. Depending upon which muscles are paralyzed, the 
disturbance of speech may vary with different letters, as mentioned at 
the above-named place. We recognize sHght anarthritic disturbances 
of speech by requiring the patient to pronounce difficult words quickly, 
especially such as contain many consonants. The slightest degree of 
bulbar dysarthria, on the other hand, is sometimes only revealed by 
the very decided tendency to weariness on the part of the muscles of 
speech ; if the patient begins to recite the alphabet or to count continu- 
ously, he starts off very well, but soon his words become indistinct. 

Simultaneously with this disturbance of speech, the voice, from 
paralysis of the palate, is often nasal (or also a kind of " clod-voice "), 
or the voice has a monotone, or it is inclined to change to a falsetto. 
Regarding swallowing, see page 494. 

Scanning speech : sounding like the speech of a rider of a horse 
that is trotting ; there are sharp changes of rhythm, unnatural pauses, 
sudden, "explosive," and then, again, snapping pronunciation of words. 
It is particularly characteristic of multiple sclerosis. 

Hysterical dumbiess is a complete loss of speech, and generally also 
of the voice, which occurs suddenly, and generally after an attack of 
hysteria, which lasts anywhere from days to years and may suddenly 
disappear. The mobility of the tongue is normal. 

1 See p. 499. 



EXAMINATION OF THE NERVOUS SYSTEM. 503 

II. Aphasic Disturbances, Disturbance of Graphic Communication 
(of Mimicking, of Singing). 

In order to understand these conditions it is necessary to make 
some fundamental explanations regarding the processes of acquisition 
and use of speech, of writing, and also of mimicking. 

Speech and writing are both means by which we give sensible ex- 
pression to our conceptions and thoughts, which can be grasped by 
others through the ear and eye. Again, by the conception of the word 
spoken and written by others we partake of their conceptions and 
thoughts. Speech and writing have come into use among men by 
agreement for the purpose of making their thoughts understood. There 
are many different languages, and every spoken or written language 
must be learned by practice. Now just as the impressions which the 
spoken words make upon the ear and which writing makes upon the 
eyes are fine and complicated, so too the muscles of speech by which 
we utter words and of the hand and arm by which we write words are 
fine and complicated. Therefore we acquire the ability to understand 
the speech and writing of others, and in turn to utter speech and to 
form the characters, by accumulating in the cortex of our brain a store 
of images of these signs. 

Let us proceed from speecJi, because this is first learned. The 
child acquires it, in the first place, by collecting acoustic images of re- 
membrance, images of the sound of words collected from the letters, 
words and sentences spoken by others. It then itself proceeds to pro- 
duce these sounds by trying to imitate them ; it regulates them by the 
ear, it improves, and finally acquires the difficult and fine control of the 
muscles for speech required for the production of sound. This can 
only be done by remembering the complicated motions necessary for 
the enunciation of speech — that is, by preserving the recollection of 
them in the brain. 

Increase in the development of a language is marked by an increased 
number of conceptions, increasing in definiteness and fineness of grada- 
tion, first of the concrete and then of the abstract. Next we conceive 
of the images of the sound of words and the complexes of motion for 
their production stored at two different parts of the cerebral cortex ; 
but perception, the understanding, rules over both, although not con- 
centrated at a circumscribed spot, but as the result of the co-operation 
of innumerable tracts and cells. The images of the sound of words 
heard produce conceptions, the conceptions in turn produce again the 
images of the sound of words, for we are able to cause a word to sound 
interytally, and the conceptions produce the complexes of word-move- 
ments : we speak audibly a word which we think of But in this way 
it is conceivable that an image of the sound of a word, coming through 
the ear, directly excites a complex of word motion without the stimula- 
tion necessarily passing through the understanding, for we are able to 
speak words that have been heard without thinking about them — that 
is, to transfer an image of the sound of a word directly into the spoken 
word, as we can also repeat the words of a foreign language which we 
have not understood. 

We now come to writinsr. There are stored in the brain the 



504 SPECIAL DIAGNOSIS. 

images of the recollected written signs of words and sentences which 
we have read, and likewise complexes of motion for the right upper 
extremity for the production of the images of writing. The image of 
writing which we have read touches the corresponding conception, the 
conception in turn produces a complex of writing motion : we write 
down a word we have thought of; but the conception may produce 
inwardly an image of the written word : close the eyes and try to see 
some word thought of Lastly, the seen image of writing may produce 
the complex of writing motion without the aid of conception : we are 
able to copy " thoughtlessly," " mechanically." 

And now let any one think of the images of the sound of words 
stored in the brain and the complexes for producing writing in 
manifold connections, associations, which associations, however, pre- 
viously exist, as they enable us to learn to read and write. All these 
complexes or images of recollection, however, are directly connected 
with the faculty of conception, at anv rate most of them, and possibly 
all. 

In this way it comes about that each of these images of recollection 
may be produced, innervated from different sides. And indeed there 
may be produced : 

1. The representatiojis of the sound of words : these come from the 
periphery through the sense of hearing. If we hear the mother tongue 
(or any other language which we know), from the conception we in- 
wardly pronounce the words. 

2. The written representation : from the periphery — that is, from 
the organ of sight if we read in a known language ; and from the con- 
ception if we inwardly represent to ourselves the printed or written 
word. 

3. The complex motions of speech: from the center representing 
the sound of words by virtue of the imitative instinct — repetition ; and 
from the mental conceptions — independent utterance of thought ; from 
the written image — we read aloud. 

4. The complex motions of writing : from written words, by vir- 
tue of our imitative instinct — copying ; from mental conceptions — 
writing out the thought ; from the sound-image — we write under 
dictation. 

The conceptions of musical notes seem to co-ordinate those of 
word-sounds, while the complex motions for producing speech and 
those which produce music (melody and rhythm) — that is, for singing 
— are co-ordinated with the laiynx and mouth. The conceptions of 
musical sounds are intimately connected with those of word-sounds, 
and the complex motions required in singing are connected, through 
association, with those required in speaking. The intimateness of this 
association appears very distinctly in the fact that when a melody 
happens to come to mind we hum the words belonging to it ; or, if the 
words come first, then we hum the melody. Sometimes this humming 
is a purely automatic act, for both the text and the melody are articu- 
lated involuntarily together. But, again, sometimes the internal re- 
sounding follows the articulation or act of listening, and from this inter- 
nal impression the articulation is first produced. 

Now to these innervations there belong tracts [of communication]. 



EXAMINATION OF THE NERVOUS SYSTEM. 505 

Those which conduct the impressions to the mind from the periphery 
we understand very well — the acoustic and optic nerves. Further, 
there must exist very manifold combinations, association tracts, between 
the conception and the four different centers themselves [mentioned 
above], but it is very difficult to obtain an exact presentation of these 
combinations. 

For instance, Kussmaul supposes that the tract from the center of 
ideas to that for the complex motions of speech goes through the 
portion which takes note of the sound of the word ; hence he assumes 
no direct innervation of the center of the complex motions of speech 
from that of ideas, though others think there is. Likewise, there is a 
dispute whether there is a direct communication from the written repre- 
sentation, or whether there is a communication with the center for the 
complex motion of writing, etc. only through another center. We will 
only bring forward one instance, for the sake of illustration. The fol- 
lowing acts, done without understanding by persons in health as well 
as by sick persons — repeating, reading aloud, copying, or writing from 
dictation — make it plausible that direct communication exists between 
the sensory and motor-centers, which therefore do not go through the 
center for ideas. But there is no doubt that in regard to this there are 
very considerable individual differences, particularly dependent upon 
the degree of cultivation and the intelligence. 

Of course we also understand the tracts which peripherally lead 
from the " motor-speech and writing-centers " in general run with the 
pyramidal tract to the motor nuclei of the bulb, or to the cervical en- 
largement of the spinal cord, and from there to the respective motor 
nerves. Also the situation of the tract for speech within the pyramidal 
tract is partly known.^ 

Likewise the situation of the center for the perception of speech 
and writing, as well as for the centers of the complexes of motion for 
producing sound, is known. Two of these, speech- and hearing-centers, 
are unilateral, and are situated only in the left hemisphere ; the center 
for the perception of the images of writing, on the other hand, possibly 
exists on both sides. 

The center for the motor complexes of words, the motor-speech 
center, is located in the third left frontal convolution (Broca) ; the 
center for the images of acoustic recollection, the sound-image center, 
is in the left temporal lobe in the first temporal convolution (Wernicke). 
The right hemisphere has nothing to do with language, except in left- 
handed people, in whom sometimes this center is located in the right 
instead of in the left hemisphere. 

The center for images of optical recollection (images of writing) is 
to be found in the optical cortical field of the occipital lobe, either on 
both sides or, more probably, only on the left. A center for the com- 
plexes of writing motion formerly was assumed to be in the second left 
frontal convolution ; but it seems that such a secluded center does not 
exist. 

Observe that the centers all lie within the respective motor and 
sensory cortical fields. 

These very different quahties, acquired by practice, may each singly 

1 See p. 418. 



5o6 SPECIAL DIAGNOSIS. 

or several together be lost by reason of local disease of the respective 
parts of the brain. When the organ of hearing remains perfectly- 
intact the innervation from the periphery of the conception of the 
sound of words — that is, the abihty to understand the words of one's 
native tongue — may be lost : there is word-deafness [" inability to 
understand spoken words, although they are heard as sounds, while 
printed or written words are understood " — Billings], loss of intellect- 
ual perception of sounds. Even when the muscles of speech are per- 
fectly normal the ability to employ language to express one's ideas, 
through the innervation which results in the complex motions neces- 
sary to make use of the appropriate word in the native language, may 
be lost — motor or ataxic aphasia (or, as Kussmaul designates it, '* the 
purest form of ataxia aphasia "). The arm may be in perfect condition^ 
and yet we may not be able to write ; or the eyes may be intact, and 
yet we cannot read — agraphia, alexia. But since the different capacities 
under consideration — the understanding and formation of words, the 
understanding and production of writing — are in a very manifold way 
connected with each other, these disturbances almost never occur 
singly, but as a complex of disturbances. 

The expressions " acoustic amnesia " for word-deafness, ** visual 
amnesia " for loss of intellectual perception of sounds, seem to us to 
be very useful, more so than the German designations formed upon a 
different principle. The only objection is that these expressions may 
be confounded with the idea of amnesia discussed later on (page 508). 

The study of these things has proceeded from the observation of 
the disturbances of speech in the narrowest sense ; that is, of speaking 
(Boilliaud, M. Dax, Broca). For this reason, and because all disturb- 
ances that come under consideration apply to speech in the broader 
sense (spoken and written speech, with reference to its comprehension 
and production), w^e class together, not at all incorrectly, all the con- 
ditions under consideration by the designation of aphasia, aphasic dis- 
turba7ices. 

We mention now in the following details only those two manifesta- 
tions which may be most sharply distinguished, while for all the details 
we refer to the special works.^ 

I. Word-deafhess (Kussmaul), Sensory Aphasia (Wernicke). 
(The two conditions are not wholly identical.) Word-deafness is 
caused by a local disease (loss of blood, softening, tumor, abscess, or 
trauma) in the region of the center for images of sound — the left first 
temporal convolution. The patient hears every word, but it sounds to 
him as any healthy person hears a word that belongs to a language 
which is wholly strange to him. The mother tongue, so far as the 
understanding of the hearer is concerned, has become a foreign, 
unknown tongue ; also, ability to repeat and to write from dictation is 
wanting. But, again, sometimes the understanding of writing may fail 
(alexia), and with it the ability to read aloud (see page 511). 

But, in opposition to this, the power of volitional writing and to 
copy written characters, and further, volitional speech, are preserved. 
Nevertheless, we generally observe a disturbance in this also : very 
often the wrong words are used, because words that are related by 

^ See also the '-schema" of Lichtheim, p. 511. 



EXAMINATION OF THE NERVOUS SYSTEM. 507 

sense or sound are, from unrestrained association, pronounced and 
strung together (^paraphasia), or it may be distinctly noticed that 
the correct words are employed, but they are distorted by repeti- 
tion of syllables, dropping of syllables, transposition of letters or 
syllables {literal aphasia, syllable-stumbling). Moreover, both condi- 
tions sometimes have relation with amnesia (" amnestic aphasia^' see 
page 508). 

2. Atactic aphasia (Broca's aphemia, Wernicke's motor aphasia) 
is a symptom of the motor-speech center in the foot of the third left 
frontal convolution, or of the ** speech-tract " from these downward. It 
consists in this, that the patient is unable to communicate his thoughts 
by words : he cannot name objects presented to him, although he 
promptly shows that he recognizes what they are in that he knows 
how to use them correctly ; if told the name of a given object, he can- 
not repeat its name, though he moves his lips and tongue with the 
greatest zeal : simultaneous with this there usually is diminution of the 
power to voluntarily write or to write down what is heard (or write 
from dictation) — agraphia — with the exception of the ability to tran- 
scribe from copy, which is usually retained. Thus, in pure cases, there 
is perfect understanding of what is said and also of what is written, 
and hence there is neither word-blindness nor word-deafness. 

But in one respect the condition of most patients of this character 
is still somewhat obscure : with reference to the question whether they 
are able to mentally produce the sound of the word, to conceive of its 
sound — i.e. to mentally sound the word. According to Lichtheim, it 
is probable that in most or in all such cases this capacity has also been 
completely lost. But regarding this point it is very difficult to form a 
positive opinion with respect to these patients. 

We cannot refrain from dwelling a little upon this question.^ We 
must confess that in these cases we have found that the method 
employed by Lichtheim, though ingenious, is very uncertain. In 
order to determine whether the word which designates the given 
objects is mentally correctly sounded, he requires the patient to tell 
how many syllables there are in the word or to press the hand as 
many times as it contains syllables. It is assumed that when an object 
is presented to a patient there arises in his mind a conception of the 
sound. What designation does he think of? I hold up a knife before 
him — does he think " a pocket-knife " or ** knife ? " — a drinking-glass : 
** a drinking-glass " or a " glass ?" — " pocket-handkerchief" or a '' hand- 
kerchief?" I admit that there are substances about which there is no 
doubt, but one would be easily inclined to hold that the number of 
syllables was wrong, and yet the patient thought he had understood 
and had spoken correctly. 

There are slighter f onus of atactic aphasia, which only show a slight 
defect in the command of language : single words are omitted or single 
words are defectively pronounced: '' doltor," " dolner," for doctor; 
" lit," for lip ; I am *' benter," for better, etc. ; that is, there is a literal 
ataxia, syllable-stumbling. But often the patient dwells upon only a 
few words or only one, or even a single syllable, which is constantly 
employed for everything, as was the case with a patient reported by 

1 For further regarding the examination of patients with aphasia, see below. 



508 SPECIAL DIAGNOSIS. 

Striimpell, and whom we have watched for years, who could only say 
"bibi, bi-bi-bi-bi-bi." We also have cases oi paraphasia. 

An atactic-aphasic patient who, before becoming affected, was a 
good singer, may lose the power of singing as well as of speaking, and 
yet the " ear " may be retained : he hears when he himself or some 
one else sings a false note. But though the speech may be lost, he 
may still retain the power to sing the melody of a song, and then it 
may happen that with the melody he may automatically articulate the 
words to which it belongs, although he cannot articulate them without 
the melody.^ 

These conditions, relatively simple and easily understood, are how- 
ever generally compHcated by accompanying anomalies of reading and 
writing. The phenomena of disease thus become very manifold and 
often difficult to explain, the more so because, regarding many of the 
associative relations between the individual functions, we still have only 
uncertain conceptions, and, moreover, because the peculiarities of indi- 
vidual persons play a large role. To mention only a single example : 
it is in general assumed that the motor-writing center is innervated, not 
directly from the conception, but by this only through the motor- 
speech center.^ This opinion is based upon the circumstance that 
motor aphasia is frequently combined with loss of the ability to write 
at will. However, it seems to be undubitable that many persons in- 
nervate the writing-center through the sound-image center, that even 
persons accustomed to write directly innervate the writing-center from 
the conception. Disturbance of the motor-speech center in such per- 
sons will not be followed by agraphia. This one example suffices to 
show how great difficulties are here presented. 

Apart from the destruction of centers, there also are complexes of 
symptoms which can only be explained by interruptions of tracts of 
associations between the centers. A study of the scheme of Lich- 
theim, given further below, will throw light upon this point. Let it 
only be mentioned here in particular that paraphasia and paragraphia 
seem to point to an interruption of the tract between the sound-image 
center and the motor-speech center. 

There is another disturbance which plays an important part in all 
forms of aphasia, and which presents a special group of symptoms : it 
is amnesia, amnestic aphasia. It has no definite localization. 

The patient presents a perfect picture of a person who is endeavor- 
ing to speak a foreign language which he only slightly or very imper- 
fectly understands. An object is held up before him : he is not able 
to name it ; he repeats it without understanding it, or he remarks : 
" Yes, certainly, that is the word ; " or he hits upon the correct word 
through association, as upon the number of fingers held up before him, 
by counting, " One, two, three, four — correct : four." This amnesis 
manifests itself only with reference to certain kinds of words, as for 
proper names, or chiefly for those representing the most concrete ideas 
(Kussmaul). 

Amnesia can be mixed with the different forms of aphasia; the 

1 In connection with this, the reader is referred to p. 504 for what was said regarding the 
connection between the complex motions of speaking and singing. 
^ Compare Lichtheim's scheme, p. 511. 



EXAMINATION OF THE NERVOUS SYSTEM. 509 

former may be very indistinct — even for a time or continuously may 
predominate over the aphasia ; but it also occurs in all possible con- 
ditions that do not at all belong here — senile dementia, disease of the 
brain of all kinds, in convalescence from any very severe illness, etc. 
With Lichtheim we do not count these cases as aphasia. 

Mode of Procedure in Testing for Aphasia Disturbances. — 
We look for any possible aphasic symptoms whenever there is disease 
of the brain, but especially with any patient who has had an attack of 
apoplexy, and particularly when there is right-sided hemiplegia. 

It is evident that the examination of these patients is often interfered 
with, either because of their mental hebetude — dimness of perception 
— or the inability to think and the loss of memory which they exhibit. 
Those patients can only be exactly examined in whom the general 
effect of the injury has passed off; and the most interesting cases are 
those where, after the indirect local symptoms ^ have disappeared, an 
aphasic assemblage of symptoms remains behind as a unilateral dis- 
turbance. 

In the first place, we ascertain whether there is amnesia : if the 
patient can, we have him count, but further we test him by requiring 
him to name objects placed before him. If he fails to do this, we give 
him the name of the object and have him repeat it. If he can do so 
(either with or without apparent understanding), he is not atactic- 
aphasic, but amnesic. It is to be remarked that occasionally amne- 
sia may simulate all — atactic aphasia, word-deafness, word-blindness, 
agraphia. 

We now proceed to test for possible word-deafness by engaging the 
patient in conversation, by requiring him to do something, as to touch 
his nose, or by directing him to take something in his hand — a knife, 
pocket-handkerchief, etc. We must be careful to avoid making any 
kind of gesture, also looking in the direction of the object named. 

Hereupon we look for signs of atactic aphasia, requiring him to 
speak and to repeat ; further, for evidences of paraphasia, literal 
aphasia. If the patient is atactic-aphasic, then we must always make 
the effort to discover whether he has the inner sense of words.^ 

After these things we conclude the test by having him read aloud 
(that is, read with understanding), have him write, compose, write 
from dictation, copy. With persons who were formerly known to 
have had a musical ear or could sing, it will be well to inquire whether 
they retain or have lost these powers, or, especially, what is the relation 
of the singing of the air and hearing the music to the understanding 
and speaking of the words that belong to it. 

Schemata. — In the examination of an aphasic patient the results are 
often confusing, and hence it is very advantageous to arrange them for 
analysis in accordance with a scheme. There are a great number of 
such schemata ; we mention only those given by Kussmaul, Charcot, 
Wernicke, and Lichtheim. In using them, it should be clearly remem- 
bered that they furnish a graphic picture of the functions and the asso- 
ciations which bind them together, but that they cannot present the 
facts as they actually exist, which it is impossible in any way to do. 
Nevertheless, these pictures assist one to understand a given case 
1 See p. 423. 2 See p. 507. 



5IO 



SPECIAL DIAGNOSIS. 



by furnishing a frame-work for recollection, being as it were a skel- 
eton. 

An excellent graphic scheme is that of Charcot, which is given 
below. It gives the four centers in their position in the brain, arbitra- 
rily assuming a secluded writing-center. If we examine the connections 
of these centers with each other and the double arrows drawn upon 
them all throughout, we notice that Charcot assumes that each center 
may be innervated from every one of the others. That, however, 
ought not to be thought to occur in every single individual ; on the 
contrary, in some these connections are more developed than in others 




Fig. 179. — Charcot's diagram of aphasia, drawn by Marie. 

The designations are the same as in Lichtheim's diagram. The centers are represented as being in those 
centers of the cortex where they are to be looked for ; the light hatching around A and O indicates the gen- 
eral acoustic and optical field in the cortex. [Notice the double arrows upon all connecting lines between A, 
(>, E, M. Also notice the arrows pointing centripetally toward Mm, and Ee, where the stimulation going to 
71/ and E causes the motions of speech and writing. In our opinion there is to be added the center for ideas, 
which should have a twofold connection with A, O, E, M.] 



[and those most fully developed in some cases differ from those most 
developed in others], as Charcot himself distinguishes a "visual" and 
an " acoustic " origin of thought. By this he means to say that one 
person is more influenced in the formation of perceptions by the images 
of writing, while another is affected most by the images of sound, and 
this especially applies to the complex of motion for words. 

A center of perception [or conceptions] is not shown in Charcot's 
scheme, as in fact there is no such center. But at any rate, we must 
imagine such a center and think of it as connected by a twofold means 
of conduction with all four centers. 



EXAMINATION OF THE NERVOUS SYSTEM. 



511 



We notice that from the mouth and hand centripetal arrows go to 
the respective motor-centers. They signify the conscious and uncon- 
scious sensations which go to these centers from the innervated 
muscles themselves and from the motions which they produce, and 
through which we continuously superintend the correctness of our 
coordination. 

Lichtheim's is a purely graphic schema. We present it here, and 
add the combination of possible disturbances and their signs which 
Lichtheim has arranged with reference to this scheme. Any one who 
has read attentively the preceding statements will be very well able to 




Fig. 180. — Lichtheim's diagram of aphasia. 

A, center for conception of the formation of sound [aA, conducting tract) ; O, center for conception of 
written characters [oO, conducting tract); M, center for the motions of speech {Mm, the centrifugal motor 
tract) ; £, center for the motions of writing (Ee, the corresponding motor tract) ; B, center for conception of 
ideas. The arrows indicate the direction of innervation. 



apply the scheme and table of disturbances to a given case of disease. 
But we cannot here enter upon the considerations which led Lichtheim 
to produce this scheme. For a more exact study of these points we 
recommend the classical works of Kussmaul, Charcot and their school, 
Wernicke, and Lichtheim. 



I. Interruption in M, the center for the conceptions of motion or 
the motor-speech center (atactic aphasia). 

Lost : (a) volitional speech ; 

(b) ability to repeat ; 

(c) " to read aloud ; 

(^) " to write volitionally ; 

{e) " to write from dictation {e [in the figure], 
the internal conception of the word- 
sounds). 

Retained : (/) understanding of speech ; 
{g) '' _ of writing; 

(li) ability to write from copy. 



512 SPECIAL DIAGNOSIS. 

2. Interruption in A, the center for the conceptions of the sounds 
of words {se7isory aphasia). 

Lost : id) understanding of speech ; 
{B) '' of writing ; 

ic) abihty to repeat after one ; 
(^) " to write from dictation; 
(e) " to read aloud. 
Retained : (/) " to write voHtionally ; 
(^) " to write from copy; 
iji) " to speak voHtionally. 

3. Interruption of MA. 

Intact : (a) understanding of speech ; 

(d) " of writing ; 
(<f) ability to write from copy. 

But there is (d) paraphasia ; 

(e) paragraphia (the same disturbance in voluntary 

writing) ; 
disturbance of the same kind in — 
(/) repeating after one ; 
(£-) reading aloud ; 
(k) writing from dictation. 

4. Interruption of MB : modification of motor aphasia. 

Lost : (a) power of voluntary speech ; 
(d) *' " writing, 

— as in atactic aphasia. 
But intact are not only 

(c) understanding of speech ; 

(d) " of writing; 

(e) ability to write from copy ; 
but besides (/) " to repeat what is said ; 

(^) " to write from dictation; 
(//) " to read aloud. 

5. Interruption oi Mm : modification of motor aphasia. 

Lost : All speech ; everything else intact. 

6. Interruption of AB. 

Lost : (d) understanding of speech ; 
{d) '' of writing. 

Disturbed : [c) volitional speech : paraphasia. 
Retained : (<^) ** writing; 

{e) ability to repeat what is said ; 

(/) " to read aloud ; 

i^g) " to write from dictation. 

7. Interruption of Aa. 

Lost : id) understanding of speech ; 

ip) ability to repeat what is said ; 
{c) " to write from dictation. 
Retained : (d) power of volitional speech ; 
(e) " " writing; 

(/) understanding of writing ; 
(g) ability to read aloud ; 
(k) " to write from copy. 



EXAMINATION OF THE NERVOUS SYSTEM. 513 

As an addendum we add here a few remarks upon the diagnostic 
value of the character of the writing : 

{a) Writing is the expression of thought, and for this reason it is a 
very fine test for recognizing psychical disturbances of all kinds.^ 

{b) As was mentioned above, agrapJiia belongs to the group of 
aphasic symptoms, and, in fact, it occurs in those forms which are 
completely analogous to disturbances of speech in the narrow sense : 
as total or partial agraphia, as paragraphia or literal agraphia. Like- 
wise, it was previously stated that a sharp distinction was to be made 
between volitional writing, writing from dictation, and copying. Also, 
the loss of the capacity to form strictly grammatical sentences, to make 
a correct sequence of words {agrammatisnms , akataphasia)^ shows 
itself in the writing, also, or still better than, in speaking. 

{c) Motor disturbance of the 7'ight upper extremity manifests itself 
in many cases in a very characteristic way in the handwriting : the 
different kinds of trembling, ataxia, the different varieties of writer's 
cramp. It is also worthy of note that patients with paralysis agitans 
very frequently write naturally, because, as is well known, their trem- 
bling ceases when making intentional motions. 

The value of the handwriting for diagnosis here consists chiefly in 
the fact that we may recognize early slight disturbances (the contour 
wavy) : ataxia manifested by the strokes going beyond bounds, espec- 
ially by the imperfections of the large letters. 

In paralytic dementia the disturbance of writing as well as of speech 
is extremely well-marked. This shows the psychical disturbances : 
delirium with exaltation or dementia ; there is agrammatismus, akat- 
aphasia, paragraphia, especially literal paragraphia in an extraordi- 
narily high degree ; lastly, there may be motor disturbances of the 
upper extremities : trembling, ataxia. 

SENSE ORGANS. 

The ^ye. — In considering the relations of the diseases of the eye 
to internal diseases, those in connection with the diseases of the 
nervous system are of very much the greatest importance. 

We find the eyes, or the function of sight, sympathetically affected 
in a great variety of ways in diseases of the nervous system. We 
observe disturbances which exhibit the more or less direct results of 
disease of the nerves or of the brain. They are — paralyses, less 
frequently spasms, of the outer and inner muscles of the eye ; dis- 
turbances of the different qualities of vision itself, from lesion of the 
sensory tract at any point from the optic nerve to the cortex ; neuritis 
optica (choked disk), which, on the other hand, may itself cause dis- 
turbance of vision. Other conditions, which are co-ordinate to the 
diseases in which they occur, oppose these conditions. They are of 
extremely varied character. We mention as examples atrophy of the 
optic nerve in tabes dorsalis, multiple sclerosis, embolus of the central 
artery of the retina with simultaneous embolus of the fossa of Sylvius, 
syphilitic iritis or retinitis in syphilis of the brain. 

Likewise, the disturbances of the apparatus of vision, occurring with 

' See the text-books upon Psychiatria. 
33 



514 SPECIAL DIAGNOSIS. 

any other internal diseases, may be either co-ordinated conditions or 
sequent phenomena of those diseases. Of the former category we 
name as examples choroidal tuberculosis in acute miliary tuberculosis, 
retinal hemorrhage in general hemorrhagic diathesis (sepsis, pernicious 
anemia), the various manifestations of syphihs, etc. As a sequent 
phenomenon we have embolus of the retinal artery in endocarditis 
aortae or mitralis, possibly cataract with diabetes mellitus, etc. 

We give these instances in order to show in how great a variety of 
ways the disturbances of vision may occur as symptoms of other dis- 
eases. In what follows we cannot classify the subject matter according 
to the points of view mentioned above. We rather proceed in accord- 
ance with the course of an examination of the eye. 

1. Movements of the Eye. — As is well known, these take place, in 
part at least, in a very complicated way, by the co-ordinate action of 
the muscles of the eye. Paralysis or spasm of the outer muscles of 
the eye causes a defective motion of the eye and disturbs its binocular 
motion, which we designate as stj^abismus. If the strabismus is due 
to spasm, it is present in all positions of the eye ; but if dependent 
upon paralysis, then it has a different relation. In slight paralysis 
(paresis) of a muscle strabismus only occurs when a motion of the eye 
is made which is in a considerable degree dependent upon the co-oper- 
ation of the muscle paralyzed ; on the other hand, in more marked 
paralysis strabismus may be almost always present. It is only absent 
when the eyes are brought into a position which corresponds with an 
especially marked relaxation of the paralyzed muscle. In long-con- 
tinued paralysis of one or more muscles of the eye contracture of the 
antagonizing muscles also takes place, in consequence of which con- 
dition strabismus is always or almost always present. Lateral strabis- 
mus is designated as divergeitt or convergent, according as there is 
divergence or abnormal convergence of the axis of vision. 

The direct result of strabismus is double-vision, or diplopia. This 
results from the fact that in fixing an object whose image only falls 
upon the macula of the normal eye in the one whose muscle or mus- 
cles are paralyzed, it falls to one side of the macula, and at varying 
distances from it, according to the degree of the strabismus and the 
distance of the fixed object from the eye. In consequence of the 
double image the determination of the position of an object in space, 
and with it the judgment of the patient with reference to his own 
position, is disturbed. Hence, primarily there is difficulty in taking 
hold of objects and in walking ; there is dizziness {vertigo of the ejye), 
and this is most marked when there is diplopia in looking downward 
(paralysis of a rectus inferior, of an obliquus superior). But after long- 
continued strabismus double vision disappears, for the patient learns to 
voluntarily shut out the abnormal eye. 

If it happens to be a case where there is paralysis or spasm of the 
muscles of both eyes which effect the conjugate motions of the eyes 
(as the rectus internus of the right and the rectus externus of the left 
eye), then we speak of conjugate paralysis of the muscles of the eyes 
or conjugate spasm of these muscles ; for the position of the eyeball 
we employ the designation conjugate deviation. 

Paralysis of all or of almost all of the muscles of an eye results in 



EXAMINATION OF THE NERVOUS SYSTEM. 515 

protrusion of the ball — exophthahnos paralyticus. Marked or total 
paralysis of the oculomotorius produces, besides the paralysis of the 
eye/ also ptosis (depression of the upper lid), dilatatiojt of the pupil, 
paralysis of accommodation (paralysis of the levator palp, sup., of the 
sphincter of the iris, of the muscle of accommodation). 

Deviation of the eye in which the paralysis or spasm is located is 
termed the primary deviation. In cases of paralysis there occurs in 
the normal eye a so-called secondary deviation if we have the patient 
cover the normal eye and then have him look with it at an object 
which has been fixed by the diseased one.^ 

We employ our own individual judgment in determining a paralysis 
of the muscles of the eye by controlling the position of the eye of the 
patient while he is looking at a distant object and from the accommoda- 
tion ; also, especially by motions of the ball sideways, upward, and 
downward ; moreover, we test the patient by having him look at 
objects in different directions, and then question him as to double vision 
and in what relation the objects stand to one another. 

Mode of Procedure in Determining Double Vision. — We hold up a 
finger about a meter from the patient, move it up and down, to the 
right and then to the left, and hold the finger steadily in the position 
in which the patient has a double image, and then have that position 
described by him. Then we suddenly close one eye : the patient now 
declares which image has disappeared. In this way we determine to 
which eye each one of the double images belongs. Or we take a 
lighted candle as the object of vision, and alternately cover an eye 
with a piece of colored glass, and then, of course, the image presented 
to this eye is colored.^ 

In regard to tlie significance of double vision, it is first to be stated 
that when the balls diverge the images are crossed ; when there is 
abnormal convergence, they are on the same side (on the side of the 
convergence). All the rest follows from what will now be said where 
we collate the function of individual muscles of the eye and the effects 
of paralysis. 

M. rectus externus (N. abducens) rolls the eye outward. Its 
paralysis, according to its degree, produces convergent strabismus, 
which is manifest either in looking straight ahead or in looking only 
toward the side whose external rectus is affected. The double vision 
is also upon that side. 

M. rectus internus (N. oculomotorius) rolls the eye inward, an- 
tagonizing the preceding. When it is paralyzed the in-rotation of 
the ball is imperfect; there is divergent strabismus, crossed double 
vision. 

M. rectus superior (N, oculomotorius) rolls the eye upward and at 
the same time a little inward. Rectus superior + obliquus inferior 
acting together simply roll the ball upward. Paralysis of the rectus 
superior limits the motion upward ; the abnormial eye stares downward 
and a little outward : there is double vision when looking upward ; the 
image of the paralyzed eye is superimposed upon that of the other. 

M. rectus inferior (N. oculomotorius) rolls the ball downward and 

^ See below. 2 Upon this subject, see works upon the Eye. 

^ For further regarding this subject, see works upon the Eye. 



5l6 SPECIAL DIAGNOSIS. 

slightly inward ; acting with the obliquus superior there is simple down- 
ward motion. Paralysis of the rectus inferior : in looking down, the 
paralyzed eye does not move, but remains directed upward and a little 
outward ; there is double vision, with one image above the other, the 
lower being that of the abnormal eye. 

M. obliquus inferior (N. oculomotorius), if it is paralyzed, in looking 
upward we have the action of the rectus superior alone : the eye turns 
somewhat inward. There is double vision upon the same side, one 
image is above the other or they are side by side, particularly in 
looking upward. 

M. obHquus superior (N. trochlearis), if this is paralyzed, then in 
looking down the rectus inferior acts alone, turning the eye somewhat 
inward. There is double vision upon the affected side, especially when 
looking downward. 

Some of these paralyses, if they occur singly, can be easily recog- 
nized, and this is especially true of those of the recti. But when 
several are combined, particularly if the obliqui are involved, there is 
often the greatest difficulty in making out the exact lesion. A com- 
bination which may occur frequently is paralysis of all the muscles sup- 
plied by the oculomotorius, with which we may then also have the 
internal muscles of the eye involving the levator palpebrse superioris. 
With this total paralysis of the ocidomotorius the eye is rotated outward 
(the action of the abducens), there is some exophthalmia, the pupil is 
dilated and remains so in the presence of light, and there is absence 
of power of accommodation. 

By nystagmus, or oscillation of the eyeball, we understand very 
slight clonic jerking motions of the ball. They are generally conju- 
gate. If they take place in a horizontal direction, then we speak of 
horizontal nystagmus. It is often most distinct in fixing the eyeball, 
but particularly with marked rotation movements of the balls sideways 
or in a vertical direction. 

Nystagmus is one of the principal symptoms of multiple sclerosis, 
but it also occurs in cerebral affections of the greatest variety. 

The diagnostic significance of paralysis of the muscles of the eye 
varies very much : paralysis of several muscles of only one eye always 
points with considerable probability to the base of the brain or to the 
orbital fissure and orbit, and this is particularly apt to be the case if, 
at the same time, there is evidence of a lesion of the optic nerve (dis- 
turbance of vision, unilateral choked disk). Progressive paralysis of 
the muscles of both eyes, sometimes ending in total paralysis of these 
muscles, indicates a progressive nuclear paralysis {ophthalmoplegia 
externa). It is difficult to estimate the symptomatic value of con- 
jugate deviation with reference to topical diagnosis. When it is 
present we should always first think of the possibility of a lesion of 
the posterior corpus quadrigeminum or its neighborhood; but aside 
from this, conjugate deviation occurs with all kinds of local disease 
of the brain, especially if recent. Hence, if the deviation is due to 
paralysis, we infer that the line of vision is toward the same side, but 
if it is a conjugate spasm, the line of vision is toward the opposite 
side. In the latter case the head is very often drawn to that side. 
Paralysis of the oculomotorius of one side and of the extremities of 



EXAMINATION OF THE NERVOUS SYSTEM. 517 

the opposite side (crossed paralysis) points with great certainty to a 
lesion of the crus cerebri, and this corresponds with paralysis of the 
third nerve. We can immediately understand this fact if we recollect 
that the N. oculomotorius dexter passes to the right crus cerebri at its 
base — that is, it passes alongside of the pyramidal tract belonging to 
the left side of the body. 

2. The Pupils. — Normally, the pupils are circular, and their size 
in individuals fluctuates within moderate Hmits. It seems superfluous 
to ^\v^ a measurement, for it is best for the physician to develop in 
himself a standard of measurement. In health the pupils are usually 
of equal width. 

The width of the pupils is determined by the action of two antag- 
onizing muscles — the sphincter pupillae (oculomotorius nerve) and the 
dilator pupillae (sympathetic nerve). 

When the pupils are abnormal, the first question to arise is : Are 
the eyes themselves normal ? Then follow these important questions : 
Is there, or has there been, an iritis or disease of the retina ? Are the 
changes in size and form, as well as mobility of the pupils due to 
these ? For particulars we refer to text-books upon diseases of the 
eye. In what follows we present an abstract of those conditions which 
have no relation to disease of the nerves. 

The Size of the Pupil. — Contracted pupil, niyosis, occurs in health 
during sleep, likewise in old age. Otherwise, myosis is always a sign 
which must awaken suspicion, and indeed is especially frequent in 
tabes dorsalis ; ^ and also, although more rarely, in progressive paraly- 
sis. The degree of illumination also has a marked effect upon the 
size of the pupil, unless rigid from reflex action.^ Hence, it is to 
be examined under moderate illumination. Dilatation of the pupil, 
mydriasis, occurs with marked disturbances of consciousness, severe 
pain,^ great anxiety, dyspnea, also with reflex rigidity, with atrophy of 
the optic nerve, paralysis of the N. oculomotorius ; lastly, sometimes 
with tabes and progressive paralysis. 

Effect of Poiso7ts. — Atropin, duboisin, cocain dilate the pupil; 
eserin, pilocarpin, morphia contract it. These effects upon the pupil 
are, in connection with other symptoms, employed for diagnosis in 
cases of poisoning with any of these substances. 

Inequality of the pupils sometimes occurs with persons in health, 
also in people with unequal refraction in the two eyes (with myopia : 
mydriasis ; in hypermetropia : myosis) ; but otherwise, inequality of 
the pupils is a suspicious symptom. It occurs in unilateral affections 
of the brain of all kinds (thus, especially with hematoma of the dura), 
with unilateral paralysis of the oculomotorius of the opticus (dilata- 
tion), and in tabes ; besides, it frequently occurs in attacks of migraine, 
where the pupil on the same side as the headache is either enlarged 
or contracted, according as there is irritation or paralysis of the sym- 
pathetic nerve. 

Reflex Changes of the Pupil. — The reflex behavior of the pupil 
plays a most important role in the diagnosis of organic cerebral dis- 
eases. 

Normally, the pupil contracts if light falls into it, by contraction of 

^ See below, under reflex rigid pupil. 2 gee p. 519, 



5l8 SPECIAL DIAGNOSIS. 

the sphincter : light reflex of the pupil. The tract of this reflex passes 
through the opticus and the chiasm, where probably a partial decussa- 
tion occurs, to the optic tract, and enters into relation with the anterior 
corpus quadrigeminum ; then it passes centrifugally through the oculo- 
motorius ; but the reflex center is still unknown. This reflex contrac- 
tion of the pupil takes place not only when Hght falls into the eye 
being examined, but also if it fall simultaneously into the other : in 
health the reaction always takes place on the same side as well as 
crossed. The test is made either in a light room by covering the eye 
with the hand and then suddenly withdrawing it, or in a room with a 
dim light by quickly going to the light. In either case the patient 
must not employ any accommodation, because the accommodation 
also causes contraction of the pupil ; hence, he must look at a distant 
object. It is best to test each eye singly by alternately closing one. 
Sometimes there is an indication for testing the crossed (" consensual ") 
reaction : we observe the changes in the pupil of the right eye while 
we vary the light which enters the left, and vice versa. In old age the 
reaction of hght is physiologically slow. 

Pain, as painful irritation of the skin, from pinching or from use of 
faradic brush, dilates the pupil through the action of the dilator. 
The reaction is slower and less marked than from light. 

Absence of reaction upon exposure to light and when there is pain 
is called ''reflex rigid pupil!' For the former anomaly we have re- 
cently adopted the shorter, clear expression of light rigidity of the 
pupils. The historical designation, " Robertson's phenomenon," fortu- 
nately has not become naturalized. 

Unfortunately, the expression reflex rigidity of pupil frequently 
occurs in literature when light rigidity is meant. 

Light rigidity is an extremely important early symptom of tabes and 
progressive paralysis. In the former disease it is also quite regularly 
combined with pain rigidity, and also in about half of the cases of 
myosis. Sometimes, instead of complete rigidity, we notice a slow 
reaction which, indeed, can only be correctly estimated by the prac- 
tised eye. Light rigidity or slow reaction, according to former statis- 
tics of Erb, occurs in 85 per cent, of all cases of tabes, which number 
on the whole is probably correct. Light rigidity is not so frequent in 
paralysis, but here it occasionally occurs a long time, even many years, 
before the appearance of psychical symptoms (Moeli, Siemerling). It 
may be combined with myosis, mydriasis, or inequality of pupils ; but 
any of these anomalies may be present without light rigidity. 

Further, reaction to light is often absent in syphilis of the central 
nervous system, when there is lesion of the reflex arch (Uhthoff), 
although usually it is not clinically demonstrable. Lastly, it occurs as 
an individual symptom in all possible diseases of the .brain (tumors, 
multiple sclerosis, injuries of the head, etc.), as well as in disease of 
the base and orbit, whenever they injure the opticus or the oculo- 
motorius, as is usually the case in diseases of the second and third 
nerve. 

In cortical blindness reaction to light is preserved. 

The examination of consensual or crossed reaction ^ may sometimes 

^ See above. 



EXAMINATION OF THE NERVOUS SYSTEM. 519 

be very nicely used in doubtful cases for determining in which part of 
the reflex arch the lesion which produces the light rigidity is located. 
For instance, if the right pupil reacts normally but the left does not, 
we then test to see whether the left pupil contracts when light is 
thrown on the right eye. If it does, its motor tract must be intact, and 
the lesion must be in its centripetal tract. If it does not react, while 
simultaneously the right pupil contracts when the left eye is illumi- 
nated, the lesion must be in the left oculomotorius tract. 

So in unilateral atrophy of the opticus, reaction of the diseased eye 
during illumination of the sound one is preserved ; but during illumi- 
nation of the diseased eye it is absent in it, as well as in the healthy 
one. Again, in unilateral complete oculomotorius paralysis in the 
diseased eye there is no reaction in that side, nor can consensual re- 
action be obtained. All in all, in liglit rigidity of the pupils it must 
always be remembered that, without exception, it points to an existing 
or impending organic disease ; hence such a disease should besought 
for, or, if not found, the patient should be kept under observation. 

Light rigidity comes into consideration in making a differential 
diagnosis between tabes and neurasthenia, tabes and multiple neuritis 
(where it is almost always absent), organic disease of the brain and 
hysteria ; also the question whether we are dealing with the results of 
an injury to the head or simulation may be decided by light rigidity. 

Light Reaction in Hemianopsia} — As in cortical blindness the re- 
action for light is not affected, so also it will be found preserved if, for 
example, in cortical hemianopsia^ a circumscribed illumination of the 
blind half of the retina be made. This is best done by throwing, with 
a convex glass, a cone of light from the side of the defective field of 
view. But, on the other hand, reaction to light is absent in all cases 
of semi-defective fields of view caused by lesion of the optic nerve, of 
the chiasm, or of the optic tract up to the respective corpus quad- 
rigeminum. In this case the lesion is just so situated that it brings 
into co-participation the reflex arch of reaction to light (hemianoptic 
pupil rigidity to light ^). 

Contraction of the pupil in convergence of the eyes or from accom- 
modation may not take place in paralysis of accommodation (this most 
frequently after acute diseases, particularly diphtheria), but it may also 
be retained. This contraction of the pupils during accommodation has 
its chief diagnostic significance in the fact that it must be avoided when 
testing for the reaction to light or pain — that is, it is generally retained 
with reflex rigidity of the pupils, 

3. Testing for the Central Sharpness of Vision, the Color-sense, 
and the Field of Vision. — (a) We test the sharpness of vision by means 
of Snellen s plate which contains test-letters of different sizes, the num- 
ber of which is represented by the distance in meters at which a nor- 
mal eye can read the type. After correcting any possible anomaly of 
refraction in either eye, we put the plate at a distance at which the test- 
letter X can be read. The sharpness of vision is expressed by a frac- 
tion whose denominator is the number on the plate, and whose numer- 
ator is the distance at which it can be read. According to the above, 
in normal vision the denominator and numerator miist be alike ; the 

1 Compare Fig, 181 and text accompanying it. ^See p. 521. 



520 



SPECIAL DIAGNOSIS. 



etc.) ; instead of this [the 
f, in case the eye is dis- 



fraction then is always equal to i (f , \ 
sharpness of vision represented by] SV. 
eased we have S V. = -|, etc/ 

As a matter of course, if we discover a diminution in the sharpness 
of vision, before we conclude that it is due to disease of the nervous 
system we must exclude any disease of the refractive apparatus. 
Here, also, the reader is referred to special works upon the Eye. 




Fig, i8i. — Schematic drawing for explaining the relation of the eyes to vision, and repre- 
senting hemianopsia. 

The direction of vision of the two eyes {BR) is very nearly parallel (the eyes heing fixed upon a distant 
object). M, macula lutea ; Ch, chiasm; Rr, Rl, right and left cortical fields of sight (occipital cortex). 
Notice a kind of semi-decussation in the chiasm, the division of the fibers in the retinae, and the character of 
the images as they appear in the cortex. H, a local disease behind the chiasm; it causes hemianopsia. The 
portion of the field of vision which disappears, and the cortical field which does not perceive the object, are 
hatched. The corresponding tracts are represented by a wavy line. 



ip) Testing the Field of Vision, FV., the " Peripheral Sight." — The 
most exact way to do this is to employ a perimeter. A substitute for 
this expensive instrument, which can be recommended to one who is 
not a specialist, is the field-of-vision chart, which has six straight lines 
intersecting each other at a point making angles of 45 degrees. Start- 
ing from the point of intersection, these lines are divided into centime- 
ters. At the point of intersection a rod of definite length stands perpen- 
dicularly to the chart, and sometimes it is screwed into the chart ; upon 
this upright is a hoop, into which the person to be examined places his 
head. It is used in the same way as a perimeter. The normal size of 
the field of vision for three or four healthy persons, with a definite length 
of the upright, is placed upon the chart. (It will be shown that on the 
outer side the field of vision is endless, because the angle is less than 90 

^ For particulars, see text-books on the Eye. 



i 



EXAMINATION OF THE NERVOUS SYSTEM. 52 1 

degrees to the direction of the Hne of sight — but of this no account is 
taken.) The pathological result is drawn upon a diagram which repre- 
sents the chart and the normal field of vision on a smaller scale. 

We recognize very decided disturbances by steadily holding a finger 
about a half meter from and in front of the eye, and then moving the 
other hand, or a light held by it, in every direction in the field of 
vision. Of course, in this case, as in all others, we are to test each eye 
singly. The great difficulty is in having the patient hold the eye fixed 
immovably. 

Cojtcentric Narrowing of the Field of Vision. — This rarely occurs in 
organic diseases of the brain. It often occurs with multiple sclerosis, 
usually from atrophy of the optic nerve,^ more frequently in neuroses ; 
and it is an especially important symptom in hysteria, " traumatic hys- 
teria," but also in " traumatic neurosis," which is closely related to this. 
With atrophy of the optic nerve there likewise occurs narrowing of the 
field of vision, which is concentric, more rarely in the form of a sector. 
Central scotoma occurs particularly in alcohol- and tobacco-amblyopia. 

The result of semi-decussation of the optic in the chiasm is the 
peculiar symptom known as homo7iyinous hemianopsia — a defect in the 
field of vision, involving about half of it, upon the same side of the 
body in both eyes. Fig. 181 explains this condition: a complete inter- 
ruption of the optic tract or of the path centrally from it, or, lastly, a 
total destruction of the sight-center in the cortex of the occipital lobe, 
from which there must result hemianopsia ; and, too, the centripetal 
conduction of the half of the retina corresponding to the side of the 
lesion will be interrupted, consequently the half of the field of vision 
opposite the lesion will be defective. Thus, homonymous hemianopsia 
indicates a lesion which affects the tract of sight between the chiasm 
and the cortex. Without doubt, this tract also passes through the 
posterior portion of the posterior crus of the inner capsule, and with 
equal certainty is in relation with the anterior corpus quadrigeminum 
of the affected side, for from here also hemianopsia may arise, or, 
when there is lesion of the corpora quadrigemina of both sides, there 
is blindness. As one portion of the optic tract, namely, that from the 
chiasm to the respective corpus quadrigeminum, includes the reflex 
arch of light reaction, in homonymous hemianopsia which originates from 
an interruption of the optic tract or in the region of the corpora quad- 
rigemina, we must expect hemianopsic rigidity of pupil.^ In homon- 
ymous hemianopsia this rigidity of pupil is said to be pathognomonic 
of lesion of the optic tract or anterior corpus quadrigeminum. 

Hemianopsia is sometimes made manifest by the patient not notic- 
ing when some one comes to his bed from that side ; by his not being 
startled when a light is quickly brought near him from the affected 
side ; or, in writing, he does not see what he has written upon one 
side of a sheet of paper, etc. 

A bilateral dropping out of the nasal half of the retina, with bilat- 
eral temporal (hence, not homonymous) hemianopsia, may be caused 
by a tumor which is situated close in front of or behind the chiasm. 
In this case the two eyes in some degree may compensate, by mutual 
action, for the defect, though, of course, very imperfectly — for binocu- 

1 See below. ^ See above, p. 518. 



522 SPECIAL DIAGNOSIS. 

lar sight is no longer possible. There occur other difficulties whose 
description does not belong here. 

Subjective sensations of vision occur in severe diseases of the eyes 
of all kinds, but especially in anemia (flimmering), with nervous sub- 
jects. Temporary partial amaurosis has great significance : a strong 
shining, generally pronounced unilateral subjective sensation of light, 
which, in some of the cases, is markedly present in migraine {inigrene 
oplitJialmique), sometimes, even during the attack, passing into hemian- 
opsia. 

ic) The Color-sense. — The central perception of color is tested by 
means of skeins of woollen yarns of as pure colors as it is possible 
to obtain. The color-sense within the limits of the field of vision — in 
other words, the size of the field of vision for the individual colors — is 
ascertained in the same way as that of pure white.^ It is not without 
importance.^ 

(<^) The results of the ophthalmoscopic examination, which are here 
of interest to us, will be found in the Appendix. 

The diagnostic value of the electrical reaction of the retina cannot 
be determined, hence we pass it over. 

Hearing^. — Functional Test. — For testing the hearing we use the 
whispering voice, which, by a healthy person, in a closed room, can be 
heard at a distance of about twenty-five meters. Each ear is tested 
separately, by closing first one and then the other by putting the point 
of the finger into the external meatus. It is to be noted that an ear 
closed in this manner hears the whispered voice a certain distance, 
sometimes from one-half to one and a half meters, by conduction of 
sound through the bones. For this reason it is almost impossible to 
determine complete unilateral deafness by means of the whispering 
voice. Another test of hearing is made by ascertaining at what dis- 
tance the tick of the watch can be heard : a healthy person usually 
hears it at a distance of one and a half to two meters, though watches 
differ greatly in respect to the loudness of their tick, and hence a 
given watch must be previously tested upon a healthy person. 

To this also extends the testing of the behavior of the conductivity 
of the bones : a normal person does not at all or only barely hears a 
watch held near to the closed ear, but hears it distinctly when it is 
brought in contact with the skull in the neighborhood of the ear. 
Persons with disease of the outer ear-passage and of the middle ear 
are in the same condition as those with normal ears when more or less 
completely closed : at a distance they hear poorly or not at all, but by 
the conduction of the bones they can hear very well. On the other 
hand, when the acoustic nerve or its terminations in the tympanic 
cavity are diseased (nervous deafness), hearing at a distance and 
through the bones are both alike diminished. 

The examination with the ear-mirror is described in the Appendix. 
Without it it is impossible to make the differential diagnosis of nervous 
deafness and of affections of the middle ear or of the external ear- 
passages. The electrical examination of the acoustic nerve (Brenner) 
has no diagnostic significance. 

Apart from the special aural point of view, the determination of a 

^ See above. ^ See text-books upon Diseases of the Eye. 



EXAMINATION OF THE NERVOUS SYSTEM. $2$ 

disease of the ear or of the sense of hearing is of importance for vari- 
ous reasons : (a) for recognizing constitutional affections (caries of the 
petrous bone in scrofula, tuberculosis, middle-ear catarrh in syphilis ^) ; 
(d) for recognizing any other local disease of the cranium, or within the 
cranium (at its base), or of the brain, which injures the acoustic nerve 
or the central conduction of hearing ; lastly (r), with reference to further 
resulting phenomena of a disease of the ear or the petrous bone, if 
they exist: thrombosis of the sinus, purulent, sometimes, also, tuber- 
culous meningitis, abscess of the brain, and facial paralysis. 

It is further to be mentioned that, on the other hand, in a normal 
condition of the hearing apparatus, a functional disturbance may be 
caused by a rheumatic facial paralysis near the origin of the nerve : 
from paralysis of the stapedius muscle, supplied by the facial, and pre- 
dominant development of the tensor tympani, there may arise a morbid 
acuteness of hearing, especially for deep tones. 

Subjective sensibility of hearing (tingling, ringing, buzzing, roaring, 
in the ear, etc.) occurs in anemia, nervousness ; further, in diseases of 
this organ of any kind; but, lastly, also in palpable nervous dis- 
eases. The latter are then generally affections of the acoustic nerve, 
as compression or neuritis, or of its terminations in the labyrinth. 
Subjective auditory sensations, as signs of disease of the acoustic 
nucleus of the oblongata, or of the auditory tract in its central course, 
or of the auditory center of the cortex in the temporal lobe, are very 
rare, if not unreliable. It is very worthy of note that tinnitus aurium 
may sometimes introduce an attack of migraine, apoplexy, or, as an 
aura, an epileptic attack. 

Tinnitus aurium may occasionally be combined with dizziness 
(N. vestibularis) ; this is much the most pronounced in Meniere's 
disease. Marked ringing in the ears may become the source of 
psychical disturbance. 

It is a notable fact that pain in the ear may sometimes be caused by 
diseased teeth, just as toothache may be caused by disease of the ear. 

In order to make a diagnosis of word-deafness, or of sensory 
aphasia, it is, of course, necessary, as a preliminary condition, to deter- 
mine whether the hearing is good. 

Lastly, attention must be especially called to the fact that a uni- 
lateral disturbance of the hearing may not only have entirely escaped 
the attention of the patient, but that even bilateral disturbances of hear- 
ing may exist for a long time unnoticed by the patient or his associates 
when it develops gradually. This occurs from the fact that w^hile 
ordinary conversation can be heard as usual by a person whose hear- 
ing is considerably impaired, whispering voices, for instance, can only 
be heard for four meters or less. 

Smell. — Testing its Fnnction. — For this purpose we may employ 
camphor, petroleum, perfumed spirit, and, as disgusting material, 
asafetida ; but not ammonia or acetic acid, because even a very slight 
amount of the vapor of these substances may irritate the trigeminus. 
We first test one side and then the other. The examination of the 
nose with the nasal speculum is described in the Appendix. 

Anosmia [loss of the sense of smell] of neuropathic origin is not 

1 See p. 253. 



524 SPECIAL DIAGNOSIS. 

very frequent. It occurs in processes in the anterior cranial fossa and 
the anterior portion of the brain which lead to compression of the 
olfactory, as from tumors, meningitis, hydrocephalus ; and here it is 
also due to compression of the olfactory. Unilateral anosmia has been 
observed as an associated phenomenon of total hemianesthesia in lesion 
of the posterior portion of the internal capsule : it then exists on the 
side opposite to that diseased. But in exactly the same way we may 
have unilateral anosmia with hysterical hemianesthesia. It is rare to 
have anosmia from lesion of the nerves passing off from the bulb in 
the ethmoid bone when this bone is fractured. 

But it is always to be remembered that the most frequent cause of 
loss or diminution of the sense of smell is disease of the nasal mucous 
membrane. It is further to be noticed that in old age anosmia some- 
times occurs without any notable pathological cause (atrophy of the 
olfactory). 

In very isolated cases the disturbance is to be referred to paralysis 
of the trigeminus ; that is, to dryness of the nasal mucous membrane 
due to the paralysis. 

Hyperosmia and osmic paresthesia (parosmia) occur in hysteria and 
insanity, and as an aura in genuine epilepsy. 

Regarding the significance of the nose as a point of departure in 
disease within the cranium, compare further on the following page. 

Taste. — Testing its Function. — We test it for the recognition of 
salt, sugar, vinegar, and quinin. We also make a test by retaining 
the same order of succession of all these substances when suitably 
diluted. Then follows the testing of a circumscribed portion of the 
tongue, as first one and then the other half of the tongue, then the 
anterior two-thirds as compared with the posterior one-third, because 
the former portion is supplied by the chorda, the latter by the glosso- 
pharyngeus. For this purpose we wipe the tongue somewhat dry, 
apply to it a very little of the [test] fluid with a glass rod, remove any 
surplus and have the tongue simply drawn back, but without any 
further motion. Although this method is somewhat doubtful, since a 
portion of the hard and soft palate, which cannot be exactly defined, 
also possesses the sense of taste, yet it seems practicable, as follows 
from its positive results in certain cases of facial paralysis. The more 
exact method of not drawing the tongue back into the mouth after the 
test substance has been put upon it, thus to eliminate the assistance of 
the palate, has the disadvantage that then even persons in health can 
only imperfectly taste. 

Ageusis [loss of the sense of taste] on one side of the tongue is 
observed with total hemianesthesia. Unilateral ageusis of the anterior 
portion of the tongue occurs also from peripheral chordal paralysis, 
and this is the case whether it involves injury of the branch of the 
trigeminus as far as the Gasserian ganglion, or of the second branch 
from there to the spheno-palatine ganglion, or of the facial between 
the geniculate ganglion and the point where the chorda is given off, or 
of the commissural portion between the fifth and seventh nerves, the 
N. petrosus superf major. Total ageusis points to hysteria. 

Moreover, the fineness of the taste, as well as of smell, varies much 
with the individual. 



I 



EXAMINATION OF THE NERVOUS SYSTEM. 525 

DISTURBANCES OF THE VEGETATIVE SYSTEM IN NERVOUS 

DISEASES. 

We must here limit ourselves to a brief enumeration of the most 
important points. 

I. General Phenomena. — The apoplectic habit (short, thick 
neck, red face, full chest, abundant layer of fat) decidedly predisposes 
to hemorrhage of the brain, but this also occurs very frequently even 
in very lean and anemic subjects. In other respects the general habit 
does not predispose individuals to diseases of the nervous system. 

Nutrition. — Nervous diseases affect the nutrition in a great variety 
of ways, sometimes not at all for a long time, and again very deci- 
dedly. It depends chiefly upon the accompanying vegetative dis- 
turbances : fever, decubitus,^ and the various disturbances of individual 
internal organs to be mentioned. 

The tuberculous nature of a local disease of the brain, or of a menin- 
gitis may be suspected (aside from possible tuberculosis of the lungs, 
scrofula, hectic fever) when the nutrition is decidedly poor. The same 
thing is true with respect to carcinoma. 

Fever. — Fever occurs in diseases of the nervous system : (a) if the 
disease itself is of an inflammatory or infectious nature ; {b) if it causes 
vegetative disturbances, as decubitus, cystitis, etc., which in turn give 
rise to fever ; (c) in many cases where the elevation of the temperature 
is supposed to be of a neurotic character: in progressive paralysis, in 
injury of the cervical spinal cord, which is not fatal (here, according to 
Naunyn and Quincke, the increase in the production of heat rises to 
44° C. [= 112° F.]), in tetanus, in severe epileptic attacks. 

Diminution of temperature is likewise seen in progressive paralysis 
and with injuries of the cervical spinal cord. 

2,, Disturbances of the Respiratory Apparatus.— Nose. — Cer- 
tain affections of the nose (nasal polypi, enlargement of the turbinated 
bones, chronic catarrh) stand in a peculiar, often causal relation to 
various neuroses, especially to bronchial asthma, to nervous affections 
of the heart. The nose, through the ethmoid bone, may be the gate 
of entrance for meningitis or abscess of the brain ; also, it is to be 
mentioned that the nose comes especially under consideration in the 
diagnosis of syphilis. 

Larynx. — V^hen there is paralysis and anesthesia of the larynx we 
must investigate its nerves and their centers in the bulb ; further, 
hysteria sometimes comes into consideration.^ We have a nervous 
cough from simple nervousness, also in hysteria. " Laryngeal crises " 
are attacks of nervous cough, which may occur in decidedly varying 
severity from slight irritative cough to attacks resembling whooping- 
cough of the severest character. They are produced by irritation of 
the vagus by tumors of the bronchial glands, or it occurs in tabes and 
hysteria. 

Dyspnea. — See what was said regarding asthma in connection with 
the nose. It occurs also in uremia, and is sometimes the most promi- 
nent symptom in chronic uremia, and in diabetic coma. Lastly, 
dyspnea is caused by functional and true paralysis of the respiratory 

1 See below. ^ See some additional remarks regarding the larynx in the Appendix. 



526 SPECIAL DIAGNOSIS. 

muscles. With the latter we take into consideration the tracts of the 
nerves, the nerve centers, especially the respiratory center in the bulb. 
Dyspnea is caused also by tonic and rapidly recurring clonic spasms 
of these muscles. In hysteria there is great disturbance of the breath- 
ing : extremely rapid superficial, or labored, deep, panting breathing, 
and temporary fixation of the diaphragm. 

Regarding Cheyne-Stokes' phenomenon, see page 8i. 

The condition of the lungs and the character of the sputum are 
chiefly regarded from two points of view : the determination of a 
tuberculosis ; and, because a connection between fetid bronchitis, 
abscess or gangrene of the lungs and emphysema, and purulent menin- 
gitis, and abscess of the brain has recently been recognized. 

3. Disturbances in the Circulatory Apparatus. — Heart. — 
This has most important relations to hemorrhages and embolic soften- 
ing of the brain : hypertrophy of the left ventricle favors the occurrence 
of hemorrhage (contracted kidney) and valvular endocarditis. In case 
of weak heart, thrombi existing within the heart (the left auricular 
appendix) may cause emboli. Atheroma of the vessels, likewise, may 
cause hemorrhage, emboli, and local thrombosis of the vessels of the 
brain. But often aneurysm of the minute arteries of the brain causes 
hemorrhages without there being any atheroma of the vessels of the 
body. Whenever there is loss of consciousness, but especially in 
every case of apoplexy, and of paralysis which is to be referred to 
the brain, the heart and vessels are to be most carefully examined. 

Palpitation and pain (angina pectoris) occur in organic disease of 
the heart, in simple nervousness (heart neuroses), in hysteria, in Base- 
dow's disease, and in nicotin poisoning. Hence these phenomena 
may have great diversity of significance. 

Much has already been said (page 203,/) regarding the anomalies 
of frequency of the pulse. Temporary, seldom continuous, quickening 
of the pulse occurs in neuroses ; but, besides, paralysis of the vagus 
or the vagus nucleus (neuritis, bulbar paralysis) quickens the pulse, 
often, also, causes a gallop-rhythm.^ 

The vaso-inotor disturbances are extremely manifold and interest- 
ing, but, according to our present knowledge, are seldom of diagnostic 
importance. There must be mentioned the unilateral paleness or red- 
ness of the head in many cases of migraine (hemicrania, sympathetica 
spastica and sympathetica paralytica) ; unilateral paleness in hysterical 
hemianesthesia. We observe cyanosis, coldness, edema, especially 
frequent in cerebral, sometimes also in spinal (poliomyelitis acut.) and 
in peripheral paralyses, and in hysteria. Sensations of heat of the 
skin in Basedow's disease — perhaps, also, in paralysis agitans — are to 
be referred to vaso-motor influences. Regarding the secretion of per- 
spiration, see page 32,/. 

Local asphyxia (cyanosis, coldness) and spontaneous symmetrical 
gangrene is observed in general neuroses, peripheral neuritis, but also 
in acute infectious diseases, diabetes, and ergotism. 

4. Disturbances of the Digestive Apparatus. — Very much 
has already been said upon this point, hence reference is made to page 
252,/: 

^ See p. 190. 



EXAMINATION OF THE NERVOUS SYSTEM. 527 

Anesthesia of the pharynx may, exceptionally, be evidence of a 
palpable disease ; it is a much more frequent and important symptom 
of hysteria. 

Increase in the secretion of saliva occurs in psychoses, idiotism, also 
in bulbar paralysis ; in all three cases — in the first from inattention, in 
the latter from simultaneous paralysis of the lips, tongue, and of the 
muscles of deglutition — the secretion sometimes runs out of the mouth. 
But, for the same reason, in bulbar paralysis the secretion escapes from 
the mouth, although it is not increased in amount. Diminished secre- 
tion of saliva is seen chiefly in facial paralysis (secretory fibers in the 
chorda tympani). 

We are also to bear in mind the nervous dyspepsias, which may be 
divided into psychical disturbances, as dyspeptic difficulties with per- 
fectly normal digestion, and nervous disturbances of secretion or of 
the motor function of the stomach. The diagnosis is to be determined 
by an examination of the contents of the stomach. 

As was previously mentioned, vomiting takes place in all kinds of 
disease of the brain, especially in those that develop rapidly ; further, 
very especially in the course of diseases of the cerebellum. It is also 
to be mentioned that there is vomiting with migraine and hysteria. 
Gastric crises are attacks of very severe, often widely-radiating car- 
dialgia, associated with vomiting (hyperacidity). They are a pecuHarity 
of tabes, and not infrequently they are for a long time misunderstood. 
Intestinal crises (attacks of coHc) and those involving the rectum 
(severe tenesmus) are more rare occurrences in tabes. 

With a number of nervous disturbances, especially in children, we 
must think of intesti?ial parasites. They may cause nervous agitation, 
marked nervousness, attacks like migraine, and spasms. It is not un- 
important, although very infrequent, that the taenia solium may infect 
the subject who has it with cysticercus [cellulosae] : thus, sometimes, 
cysticerci may develop in the brain, in the eye. 

Habitual constipation is especially frequent in all kinds of diseases 
of the spinal cord. Marked retentio alvi is very often dependent upon 
weakness or paralysis of the abdominal muscles, perhaps from abdom- 
inal pressure. 

Incontinentia alvi is partly the result of inattention on the part of 
idiots, the insane, those who are unconscious ; on the other hand, it is 
evidence of paralysis which only manifests itself either by the fact that 
the stool cannot bfe retained long after the first sense of desire, or that 
only the fluid stool cannot be held back ; lastly, that solid as well as 
fluid stools pass each time. This disturbance may occur from inter- 
ruption of the reflex arch centripetally from the rectum to the lumbar 
portion of the spinal cord, and thence again to the sphincter muscles, 
or by interruption of the tracts, centripetal and centrifugal, between 
the lumbar cord and the brain (voluntary defecation). Involuntary 
discharge of the stool likewise takes place, particularly in spinal dis- 
eases both of the lumbar cord and of the portion above it. In the 
latter case the discharge seems to be regulated by the absence of 
reflex, but without the influence of the will ; on the other hand, in 
■destruction of the lumbar cord, the reflex as well as the voluntary in- 
fluence is annulled : the sphincter is relaxed, the scybala escape as 



528 SPECIAL DIAGNOSIS. 

they are carried down from the intestine. The same thing is also 
observed in very great prostration [as in typhoid fever]. 

5. Disturbances of the Urinary Apparatus. — Oliguria, anuria, 
also polyuria, may temporarily affect hysterical patients. Polyuria (dia- 
betes insipidus) also glycosuria are observed temporarily or continu- 
ously with local diseases of the oblongata, for a very short time in 
tabes, and when there is considerable increase of the intracranial press- 
ure. On the other hand, in genuine diabetes mellitus there are 
observed a number of nervous disturbances : neuralgia, neuritis, deep 
disturbances of the nutrition of the skin and the subcutaneous cellular 
tissue, and either slowly developing or sudden coma like apoplexy. 

Cystitis, from the slightest to the most severe form, is observed 
when there is difficulty in emptying the bladder,^ and especially (but 
not exclusively) after the use of the catheter. It is particularly an im- 
portant and frequent complication of myelitis transversa and of tabes. 

Further particulars regarding the condition of the urine have been 
given in connection with the urinary apparatus itself 

Involuntary passage of the urine occurs in the insane, with idiots, 
in the state of unconsciousness, in severe diseases of any sort ; further, 
as a special form of disease in enuresis nocturna. 

Retentio et incontinentia urincE, however, have an especial role. 
With the former, the patient, when urinating, must press or wait a 
little, when the urine gradually comes in the ordinary way, or else it 
escapes very slowly in a small stream, or the bladder cannot empty 
itself at all and the catheter must be used. Incontinence often first 
manifests itself as under reflex control, but the urine is passed inde- 
pendently of the will, or simultaneously with retention there is an 
after-trickhng, or an escape of the urine while laughing, coughing, or 
in severe cases, as ischuria paradoxa : the bladder is not completely 
emptied ; it sometimes remains always abnormally full, but from time to 
time some of its contents escape ; in the most severe cases the urine 
trickles continually from the constantly-full bladder. In the latter 
cases there is complete paralysis of the bladder (generally of the 
detrusor as well as of the sphincter). 

An involuntary passage of urine which is under reflex control re- 
quires an intact reflex arch : ici) healthy mucous membrane of the 
bladder; (h) sensitive muscle; [c] nerves ; {d^ lumbar spinal cord; {/) 
muscles of the bladder — hence it occurs with an intact lumbar cord, 
but one which is cut off from the brain : myelitis transversa dorsahs, 
cervicalis, or traumatic and other spinal transverse lesion. We meet 
with complete paralysis of the bladder chiefly in lesions of the lumbar 
cord. All kinds of bladder disturbance occur, from the slightest to 
the most severe, in tabes. Differential diagnosis comes chiefly into 
consideration from the fact that disturbances of the bladder are absent 
in multiple neuritis (as against tabes) ; further, in amyotrophic lateral 
sclerosis, poliomyelitis (as against myelitis). 

We have still to mention the [frequent, but not invariable] invol- 
untary passage of urine in attacks of genuine epilepsy ; it is wanting 
in hystero-epilepsy, and so it is important for differential diagnosis. 

Bladder crises (painful tenesmus) are observed in tabes. 

^ See this. 



EXAMINATION OF THE NERVOUS SYSTEM. 529 

Lastly, it is to be cited that the most varied conditions of irritation 
of the penis (especially phimosis) may lead to enuresis, pollution, other 
nervous disturbances of various kinds. 

6. Disturbances of the Genital Apparatus. — The various 
anomalies of the male genital function may be almost entirely (with 
the exception of azoospermia and aspermatism) functional and organic, 
and in the latter case again may rest upon a nervous as well as some 
other form of disease. From the standpoint of diagnosis of nervous 
diseases the decline of the genital function is chiefly of importance in 
tabes, as against chronic multiple neuritis. On the other hand, differ- 
ential diagnosis from neurasthenia spinalis is often necessary, and it is 
to be remembered that in the latter disease there may also be long- 
continued marked functional disturbance of the activity of the sexual 
function. 

Of the female genital apparatus very little needs to be said here. 
An energetic reaction has taken place against the etiological relation, 
formerly very strongly claimed, between anatomical disturbances and 
hysteria, which reaction, in turn, is going too far. In our opinion, 
there is no doubt that in women diseases of a sexual character may 
cause hysteria, certainly more than do other conditions which tend to 
weaken the nervous system. 

The so-called painful ovary or ovarian hyperesthesia, sensitiveness 
of the hypogastric region, especially on the left side, to pressure upon 
this spot (which has nothing to do with the ovary) is not unimportant 
in hysteria and sometimes causes an hysterical spasm ; also [pressure] 
sometimes arrests an existing attack [Charcot]. Similar hysterog- 
enous zones may exist in other regions of the body in hysterical 
subjects. 

7. Disturbances of the Skin.^A number of diseases of the 
skin, apart from the special province of dermatology, rest upon a neu- 
rotic basis, as herpes, sometimes probably also pemphigus ; further, the 
so-called glassy skin ; at any rate, each of these may be regarded as a 
disease of the peripheral nerves. Herpes zoster especially, when it 
involves the intercostal nerves, has a special significance : it has its 
origin in compression of the spinal cord, in tabes, meningitis spinalis 
(here probably entirely from the roots of the nerves), in disease of the 
spinal ganglion, and in peripheral neuritis, in all these cases generally 
associated with neuralgic pains. But herpes also occurs in the region 
of any other nerves, as the trigeminus. 

Regarding herpes labialis, etc., see under acute general diseases, 
page 44. 

In all diseases of the nervous system we must search carefully for 
any evidences of syphilis, not only upon the skin but also in the other 
organs which come under consideration. 

Regarding local perspiration (see page 34) we sometimes, although 
rarely, have local anidrosis. Among the laity the loss of perspiration 
of the feet plays an important part as the supposed cause of a number 
of diseases, particularly spinal, as tabes ; it is probably a consecutive, 
and in itself an indifferent, phenomenon of this disease. 

Hemorrhages of the skin occur spontaneously in hysteria, as curi- 
osities ; punctiform ecchymoses may be observed upon the face, chiefly 
34 



530 SPECIAL DIAGNOSIS. 

in the neighborhood of the eyes after epileptic attacks. Here, also, 
we more frequently have hemorrhages in the conjunctiva. Hemor- 
rhages into the subcutaneous tissues take place after injuries received 
during an epileptic attack. The significance of hemorrhages into the 
skin and subcutaneous cellular tissue of the head (especially about the 
eyes, and of the nose in fracture of the base of the skull), is treated of 
in the works upon Surgery. 

Decubitus is an ulceration of the skin, then of the subcutaneous 
tissue and sometimes of the deeper tissues, and even of the bone itself. 
It occurs in dependent portions of the body upon which the patient's 
weight rests, and particularly where the skin covers bony prominences, 
as the sacrum, the heels, the scapula. Want of cleanliness, and lying 
upon the sacrum, especially when there is incontinence of stool and 
urine, are very marked exciting causes. 

1. Decubitus acutus (malignus) at first manifests itself as an ery- 
thema exudativum, then vesicles are generally formed, whose bases 
become necrotic, from which the destruction proceeds rapidly 'both in 
area and depth. Pressure and filth are marked causes, but pressure 
alone may produce the ominous exudative erythema, as on the inner 
sides of the knees when pressed together in cases of adduction con- 
tracture, where we once saw an enormous decubitus acutus form in a 
iQ.\N days. Decubitus acutus has been seen by Charcot in hemiplegia 
upon the posterior portion of the paralyzed side two to four days after 
an attack of apoplexy. We have observed it only in severe diseases 
of the spinal cord. 

2. Ordinary decubitus occurs only when the body lies so that press- 
ure is made upon one place and with the concurrence of uncleanness ; 
it may be entirely prevented by proper care. It also begins as an ery- 
thema, or in the form of a few pustules, or a cutaneous hemorrhage. 
It occurs in all organic paralyses, also in any kind of cachexia, if care 
is not taken to prevent it. 

Mai p erf or ant [perforating disease of the foot] is a destruction of 
the skin and deeper parts of the foot, especially of the heel [sole ?]. 
It occurs in tabes, in progressive paralysis, also in diabetes. Ulcera- 
tions of the skin or subcutaneous tissues, also the capsule of the joint 
and the periosteum have frequently been observed in syringomyelitis 
of the cervical cord. 

Growth of hair is a very notable anomaly dependent upon a neu- 
rosis. But these changes have no independent diagnostic significance. 

The nails readily become claw-like, angular, and brittle in long-con- 
tinued severe peripheral paralysis. 

8. Bones and Joints. — We observe the arrest of growth of 
bones after severe central paralysis during the period of childhood, 
and, likewise, after poliomyelitis acuta it is generally more marked 
than after encephalitis. Abnormal brittleness of the bones is frequently 
seen in tabes. In severe syringomyelitis of the cervical cord there 
are severe trophic disturbances of the bones, as fractures, periosteal 
inflammations with separation of sequestrum. 

Arthropathice of all kinds are to be observed in diseases of the 
nervous system: i. Organic arthropathia, seldom in recent hemiplegia, 
occurring more frequently as stiffness of the joints, is easily con- 



EXAMINATION OF THE NERVOUS SYSTEM. 53 1 

founded with stiffness and sensibility from contracture. It occurs in 
old hemiplegias, and is also to be observed as serous effusion with 
periarticular swelling or as severe deforming arthritis, also causing new 
formation ; both the latter occur in tabes. There also occurs in syr- 
ingomyelia severe deforming arthritis. 

2. Joint neuroses occur as painful, occasionally exacerbating affec- 
tions of the joint, sometimes with pressure points [tenderness], stiffness, 
and contracture, the two latter disappearing under narcosis, but without 
any sign of organic disease. 

Under the name of acromegalia, Marie has recently described a 
peculiar disease, which consists in a giant-like enlargement of the feet, 
hands, nose, inferior maxilla, and certain parts of the skeleton, depen- 
dent entirely or chiefly upon hypertrophy of the bones. 



Remarks upon the Diagnostic Value of the Symptoms in 
Nervous Diseases. 

In diseases of the nervous system the individual phenomena com- 
bine to form complexes of symptoms in so manifold a way (much 
more than in the diseases of any other organ-system), that the repre- 
sentation of only the most important possible combinations would very 
much exceed the limits of a brief work upon diagnosis. Moreover, 
for the introductory study of individual diseases, we must confess that 
we think the method of special pathology which compactly presents 
the picture of disease on the lines of etiology, anatomy, and symptoms 
is far preferable to the introduction of such minutiae into a text-book 
upon diagnosis. . For this reason we add here only a few general 
remarks. 

In diseases of the nervous system much more than in those of the 
rest of the organism, the impression stands out distinctly that we in 
reality have to estimate the phenomena found in a patient in two ways. 
We must ask ourselves : 

{a) What are the portions of the nervous system whose disease, 
judged by their nature and location, has caused or can cause the pres- 
ent phenomena ? This proceeds upon our knowledge of the anatomy, 
physiology, and pathological physiology of the nervous system, which 
we must acquire as perfectly as possible. 

(b) Does the picture formed by all the symptoms correspond with 
any disease with which we are now acquainted ? Then comes the 
further question : 

[c] What light does the etiology, development, and course of the 
disease throw upon its nature, and sometimes also upon its location ? 

The lines of thought designated by (a) and (U) closely interlock ; 
generally both are employed in a single case. In certain diseases, in- 
deed, we are wholly or almost wholly directed to the latter (U), the, so 
to speak, unscientific lines of thought, particularly in certain geiieral 
neuroses or functional diseases. On the other hand, we are fortunately 
able, in local diseases of the brain, of the spinal cord, and of the 
peripheral nerves, to proceed upon an almost purely anatomico-physi- 
ological basis. 



532 SPECIAL DIAGNOSIS. 

In order to make a diagnosis of the location of a local disease^ 
besides the special knowledge requisite for such a discrimination, one 
must have a certain amount of practice in making combinations, of 
which the ability to keep in mind the topography must form the basis. 
(Let it be here once more repeated that our preliminary anatomical 
remarks do not, by any means, contain all that has been positively 
determined and is interesting to know, but are rather for the purpose 
of instruction in topographical thinking). We advise the beginner, 
who wishes to train himself in this department, to begin with the 
study, for instance, of peripheral facial paralysis, the different com- 
binations of paralysis of cranial nerves at the base of the brain, and 
then to study the group of symptoms in the cerebral centers. 

In order to arive at a conclusion regarding the situation of a local 
disease it is recommended, as the result of experience, that we should 
always attempt to trace the different phenomena back to a focus ; but 
it is evident that sometimes there will be several foci. Moreover, the 
probability that there is only one focus varies with the supposed nature 
of the disease ; thus, for instance, a glioma almost always occurs as a 
single tumor, while metastatic cerebral abscesses are generally, and 
thrombotic foci of softening very often, multiple. 

In regard to local diseases of the brain we are to distinguish be- 
tween the general phenomena as respects the brain and the local symp- 
toms. We refer to what we have said above on page 423,/. 

But in all diseases of the nervous system all possible disturbances 
in the rest of the organism contain diagnostic points, and, for forming 
a judgment as to the nature of the local trouble, come especially under 
consideration in local diseases of the brain and spinal cord. We 
compare what was said upon this point in the chapter on vegetative 
disturbances ; but, especially, we must never fail, in every disease of 
the brain and spinal cord, to take into consideration the possibility of 
the syphilitic nature of the disease (when there is the slightest sus- 
picion of syphilis the treatment is to conform to it). 

Under the anatomical diseases of the nervous system, in every re- 
spect the so-called systemic diseases have a special place. In these 
conditions the disease in the nervous substance is, with more or less 
regularity, always concerned only with certain elements, which system- 
atically (in Flechsig's sense, see below) belong together, while other 
portions, even lying very close to the diseased ones, remain entirely 
healthy : the disease does not lay hold of the entire region, and thus it 
stands in sharp distinction from the inflammatory diseases and all new 
formations. But even though the systemic disease lays hold upon ele- 
ments of the same function (and indeed always the symmetrical por- 
tions of the two sides ; and these are generally, although not always, 
of the same severity upon both sides), it always produces, at least in 
its main features, a like combination of symptoms. If several systems 
are affected with disease at the same time, then we speak of the com- 
bined system-disease. Amyotrophic lateral sclerosis furnishes the 
most clear picture of a combined system-disease which may affect the 
whole cortico-muscular conducting tract from the cortex to the mus- 
cles, but always leaves all the rest entirely intact. We advise every 
one to begin the study of the system-diseases with this remarkable one. 



» 



EXAMINATION OF THE NERVOUS SYSTEM. 533 

Beside the systematic nerve-trunk degenerations, we also speak 
of systematic nuclear degenerations, in that we have somewhat modi- 
fied the idea of the system which was employed by Flechsig only 
for the bundles of fibers which showed similarity by the point of time 
when their medullary sheath was formed (and which " appeared to be 
intercalated between apparatus having objects of equal value "). 
Hence, and not incorrectly, we designate the disease itself as system- 
atic when it involves " apparatus having objects of equal value." 

In conclusion, we make a few further remarks regarding the differ- 
ential diagnosis of functional and anatomical diseases of the nervous 
system. This differential diagnosis is often so extremely easy that the 
question does not arise at all, but sometimes it is extremely difficult. 
The points of departure for the differential diagnosis are arranged in 
four categories : 

1. The first question always is whether the total picture entirely 
corresponds with a local disease, or an anatomical or functional disease. 
It is to be remarked, however, that hysteria may sometimes exactly 
simulate a local disease of the brain. 

2. There are certain symptoms of palpable disease that are entirely 
unmistakable. These are : the reaction of degeneration or rapidly 
developed and very decided atrophy and laxness of the paralyzed 
muscles;^ choked disk and reflex rigidity of pupils are also symptoms. 
Not absolutely certain, although pointing quite decidedly to a palpable 
disease, are : absence of tendon reflex ; in unilateral affections, the 
unilateral absence of abdominal reflex, and very marked disturbance of 
the bladder. 

3. There is one almost certain sign of functional disease : a sudden 
return to a perfectly normal condition after long persistence of a dis- 
eased condition, or the sudden occurrence of new and different phe- 
nomena with the disappearance of those previously existing. There 
are other signs of hysteria which, in their combination, cannot mislead ; 
these are the stigmates hysteriques (Charcot) : hysterical hemianesthesia 
of the skin and organs of sense, concentric limitation of the field of 
vision, characteristic spasms, sometimes hysterogenic zones. 

4. As regards cerebral symptoms, marked development, or on the 
other hand, the absence, of a disturbance of the sensorium and the in- 
telligence, decides the question. Also, continuous fever and rapid 
decline of strength points to an anatomical disease. 

1 Compare, further, what was said on p. 456 regarding atrophy in hysterical paralysis. 



APPENDIX 



We present here a very brief sketch regarding the examination of 
the larynx, the nose and the ear with the mirror and the revelations of 
the ophthalmoscope, so far as they are related to internal diseases, espe- 
cially to the diseases of the nervous system. Lastly, there follows a 
review of the life history of those pathogenic bacteria which have any 
part in the diagnosis of internal diseases. 

The examination with the mirror of the nose and ears can only be 
briefly touched upon, because these pertain chiefly to the diseases of 
these organs themselves, and are very rarely of significance for recog- 
nizing any other diseases. Beside, with reference to the latter view, 
we have already (pages 66 and 522) referred to the diseases of the 
nose and ears which do sometimes come under consideration. 

I. LARYNGOSCOPY.^ 

Instruments and Sources of I/ight. — Turck's reflector with a 
head-band is most frequently recommended for illuminating the throat. 
As the laryngeal mirror we employ a round mirror, with a diameter 
of 20 to 25 mm., fixed to a staff at an angle of 120 to 125 degrees. 
The staff is fixed to a handle or it is screwed into a handle prepared 
for it. 

For a source of light we may employ any sufficiently powerful oil- 
or gas-lamp. The lamp is placed close to the head of the person to 
be examined, so that the light from the reflector is thrown at the 
smallest possible angle into the throat of the person being examined. 
If it can be had, sunlight is better than artificial light. It is employed 
either in such a way that the patient sits, with his eyes closed, facing 
the sun, and the light is allowed to fall directly into the throat or so 
that the sunlight is thrown by the reflector into the throat. If the 
sunlight is glaring, we employ a special mirror with a longer focus (or 
a plane mirror), because the ordinary reflector would make a too glar- 
ing light, and sometimes even produce an uncomfortable sense of heat 
in the throat. Electric light is an excellent substitute for sunlight. 

In making the examination we sit directly in front of the patient, 
have him open his mouth, set the reflector at the proper angle, then 
warm the laryngeal mirror a little over a spirit-lamp (testing its tem- 
perature by placing it against the back of the hand), have the patient 
put out the tongue, seize it with pieces of gauze, or a napkin or hand- 
kerchief and draw it out [as far as possible. It is well to have the head 

1 Let it be distinctly understood that what is here given contains only the most essential 
points which are of use in the examination itself. They cannot and should not take the 
place of study of these subjects in a medical course. 



536 



APPENDIX. 



thrown quite well back]. Holding the mirror as one would a pen, it 
is to be slowly and carefully introduced into the mouth, and then the 
patient required to distinctly pronounce " ae," at the same time giving 
the proper direction to the mirror as it is pushed as far back as possible 
into the pharyngeal cavity, slightly pressing up the soft palate. The 
parts are now brought into view by elevating the mirror, depressing it, 
turning it now to the right, then to the left, and revolving it, both 
during quiet respiration and phonation. 

The mirror must be most scrupulously cleaned and disinfected after 
every examination. It is not necessary to employ a special mirror 
with patients who are manifestly syphilitic. 

IrritabiHty of the pharynx (strangling, vomiting) may, with prac- 
tice, be avoided. In very obstinate cases we can employ cocain. 
(See the special text-books regarding other obstacles and the ways of 
meeting them.) 




Fig. 182.— Laryngoscopic view during quiet breathing (after Heitzmann), double size. 



In the laryngoscopic image the parts that are anterior appear as the 
posterior ; on the other hand, what is upon the right hand of the 
patient remains upon the right ; the examiner has, of course, the right 
vocal cord of the patient upon his left side. 

We observe (see Fig. 182) : i. The base of the tongue, the glosso- 
epiglottic ligaments, the epiglottis, lig. aryepiglottica with the carti- 
lages of Wrisberg. 2. The arytenoid cartilage, or the cartilage San- 
torini, the false vocal cords, the sinus Morgagni. 3. The ligamenta 
glottidis vera, with the vocal process of the arytenoid cartilage. 4. 
The region between the arytenoid cartilages, pars interarytenoidea (the 
posterior wall of the larynx) ; the subchordal region, or the foreshort- 
ened trachea. The illumination must be strong. 

It is advisable for those who have had but little experience to first 
fix the landmarks by the shining white prominent true vocal cords, 
and from thence to examine the individual parts of the laryngeal 
picture one after the other. 

The examination with the laryngeal mirror is directed to three 
things : the form and the color of the parts of the larynx, and the 
position or motion of those that move. 



LARYNGOSCOPY. 537 

As to the form of the several portions of the inside of the larynx it 
is to be remembered that the representation given in Fig. 182 is, of 
course, only schematic. Repeated examinations of normal larynges 
will show the variations and fix them in mind. The form of the epi- 
glottis varies very much ; this is also true of the arytenoid cartilage 
and the false vocal cords or the opening of the ventricle of the larynx. 

The color of the mucous membrane of the larynx, with the excep- 
tion of the true vocal cords, is tolerably uniform and corresponds some- 
what with that of the hard palate. Very often the upper border of 
the epiglottis, and sometimes its upper surface, is lighter, even yellow- 
ish-red. Above the arytenoid or Santorinian cartilages, the color of 
the mucous membrane varies considerably : sometimes it is exactly 
like the other parts, sometimes darker, again Hghter, and then yel- 
lowish. The true vocal cords are shining white ; in individual cases, 
with the function perfectly normal, they are sHghtly rosy. At the 
vocal process there is a circumscribed yellowish spot. 

We must be on guard against being misled by deposits of mucus 
or of pus from the lungs. These deposits may be superficial, or may 
conceal deep ulcerations, loss of substance, croupous deposits. If in 
doubt, require the patient to cough. If still uncertain, have the patient 
inhale the vapor of steam for a few minutes, and then repeat the 
examination. 

Normally the positions and movements of the portions of the larynx 
are perfectly symmetrical, although it is to be remarked that if the 
mirror is not properly held in position, the parts may easily appear to 
be unsymmetrical. During quiet respiration, the rima glottidis is tol- 
erably widely opened — at least so that the whole breadth of the true 
vocal cords is visible; the arytenoid cartilage (cartilage of Santorini) 
can be seen between the pars interarytenoidea (posterior wall of the 
larynx) ; with active deep inspiration, the vocal cords separate from 
each other still more, so that they almost or quite disappear under the 
false vocal cords (which likewise stand apart). During phonation, the 
vocal cords come so closely together that either no slit between them, 
or scarcely any, can be seen. Generally their median edges form a 
perfectly straight line. But in individual cases, only the pares liga- 
mentosae close so sharply, and posterior to the process, vocales (that is, 
the pars cartilaginea), the vocal cords remain somewhat more apart, 
leaving a triangular space between them. 

When the glottis is closed the arytenoid cartilages come near to- 
gether and the pars interarytenoidea disappears ; on the other hand, 
the false vocal cords leave a tolerably broad space between each other, 
through which we see the true vocal cords. 

Pathological Conditions. — Since we here come upon a subject 
that has already been frequently referred to, in what follows we bring 
forward only those conditions which have relations to other internal 
diseases, and treat of them in the briefest way. 

We do not meet with paleness of the mucous membrane of the 
larynx as a local condition. Also, it is no longer of importance in the 
recognition of a general anemia, because this is much easier deter- 
mined by the paleness of the skin, lips, etc. Only one circumstance 
-needs mention, that tuberculous infiltration and ulceration, in contrast 



538 APPENDIX. 

with other kinds, as syphilitic, often accompanies a very striking gen- 
eral paleness of the mucous membrane of the larynx. Abnormal 
redness of the mucous membrane of the larynx^ without other changes, 
occurs in febrile hyperemia of all the mucous membranes and in gen- 
eral or local engorgement (the latter caused by pressure upon the 
larynx by tumors, from engorgement in the region of the cava supe- 
rior). Also, whenever there is any redness of the larynx it must, as a 
matter of course, lead us to examine most carefully for any possible 
other changes (ulcerations, swellings, etc.). 

Redness, sivelling, and sometimes secretion, are the signs of catarrh. 
Acute as well as chronic laryngeal catarrh may involve various loca- 
tions : for example, it may attack the upper portion of the larynx, 
leaving the glottis free ; it may also attack only the glottis. A simple 
catarrh is always symmetrical Acute, as well as chronic, catarrh may 
cause motor disturbances : on the one side this may be due either to 
the swelling of the mucous membrane (especially of the incisura inter- 
aryta^noidea, preventing the closure of the glottis), or, to paralysis of 
the tensor of the vocal cords or the adductors. Acute laryngitis, espe- 
cially in children, may give rise to apparent stenosis by reason of the 
swelling. 

It is to be especially remembered that chronic and recurrent acute 
catarrh, and likewise, no doubt, simple catarrh, are very frequent in all 
chronic diseases of the lungs and especially in tuberculosis. It is 
further important to remember that behind a chronic catarrh a tuber- 
culous or syphilitic (or lupous) new formation may for some time be 
concealed. A swelling which is limited to or elects the interarytenoid 
region is always very highly suspicious of tuberculosis. 

Laryngitis hypoglottica (von Ziemssen) is an especially severe form 
of acute, as well as chronic, catarrh. In this 
disease we see beneath the vocal cords some- 
times merely a soft rosy border, which can only 
be seen during inspiration ; sometimes a firm 
grayish-red, smooth or uneven lump (see Fig. 
183). It is almost always present upon both 
sides. These subchordal swellings appear to vary 
Fig. 183.— Swelling be- a good deal as to their nature : sometimes they 

low the vocal cords from • 1 1 . 1 • . 1 - 

laryngitis hypoglottica ^^c Simply duc to edema; in other cases, to a 
chronica (after Ziemssen). simple catarrh ; in Still Others, to submucous in- 
filtration. Further, such a subchordal laryngitis 
may be or may become tuberculous in its nature ; more rarely it is 
syphilitic. From the condition of the larynx alone it is extremely 
difficult to make the differential diagnosis of these specific diseases 
from simple catarrh, as well as between syphilis and tuberculosis. 
There may, however, be other alterations of the larynx present, or 
unquestionable signs in other organs, which throw hght upon the 
matter. The serious character of laryngitis hypoglottica is manifested 
by the fact that very frequently, and sometimes very suddenly, it causes 
severe stenosis. 

Marked swelling of the zvhole larynx or of certain portions of it in- 
dicates edema or phlegmon — that is, severe submucous inflammation 
which ends in abscess. Both of these will chiefly be distinguished by 




LARYNGOSCOPY. 



539 



the color of the mucous membrane, which is pale when there is non- 
inflammatory edema, even yellowish and often shaking like jelly, 
while in phlegmonous inflammation it is deep red. Midway between 
these two conditions stands inflammatory edema, which pathologico- 
anatomically and genetically cannot be sharply distinguished from 
phlegmonous infiltration. Severe phlegmon may lead to decided dis- 
figurement of the larynx (see Fig. 184). This may also be true of 
edema, as is shown in Fig. 185. Circumscribed laryngitis phleg- 
monosa usually results in the formation of abscess, or it may occasion 
a submucous or perichondria! formation of pus. 




Fig. 184. — Phlegmonous laryngitis, with 
phthisical ulcer (from v. Ziemssen after 
Tiirck). 

a, epiglottis ; b, left aryepiglottic fold ; c, left 
pyriform sinus. 




«2^ 



Fig. 185. — Extensive phthisical ulceration 

of the larynx, marked stenosis of the larynx 

from edema (from v. Ziemssen after Tiirck). 

a, right aryepiglottic fold ; b, anterior portion of 

the right cord. 



Both these conditions are extremely dangerous, because they very 
easily result in stenosis, and sometimes, if they are acute, with re- 
markable suddenness. Phlegmonous laryngitis sometimes results in 
the formation of pus in the larynx (especially perichondritis), or its 
neighborhood (as angina Ludovici). Laryngeal cartarrh very seldom 
terminates as a phlegmon ; foreign bodies, and substances that irritate 
chemically and as escharotics, may produce it; and lastly, it occurs in 
various acute infectious diseases, either resulting in catarrhal or ulcer- 
ative processes, or, it would seem, as independent metastatic diseases. 
Inflammatory edema may be the result in all of these cases, besides 
or instead of phlegmon. Simple edema is rare and chiefly occurs 
with general dropsy of all kinds, and in local obstruction (as in struma, 
mediastinal tumors). 

Ulceration seldom occurs in the larynx with simple catarrh, more 
frequently in acute infectious diseases, especially in typhus abdominalis 
[typhoid fever] and variola, but most frequently in syphilis and tuber- 
culosis. We limit ourselves to a description of the two last-named 
forms. 

Syphilitic tdceratioji in the larynx occurs almost exclusively in 
connection with pharyngeal syphilis. It, by preference, attacks the 
upper section of the larynx, but it may appear in the glottis. In the 
majority of cases a single ulcer is observed. The ulcers have reddened 
edges, with a more or less shallow, whitish deposit upon a vocal cord 
or the epiglottis, or there is a very deep crater-like cavity with a 
whitish deposit and sharp or swollen border. By the absence of knotty 
elevations of the border they are sharply distinguished from carcino- 
matous ulcers. On the other hand, it is often difficult to distinguish 



540 



APPENDIX. 



them from tubercular ulcerations. Here the differentiation is made by 
other signs of syphilis or tuberculosis that may be present. 

Regarding guimnata of the larynx, see below. Syphilitic infiltra- 
tion without ulceration and without other associated signs of syphilis 
are very difficult to diagnose. These slighter syphilitic changes, more- 
over, very seldom come under examination, because they do not 
usually cause any inconvenience.^ 

Tubercular ulceration develops from tubercular infiltration. The 
principal location to be mentioned is the region of the interarytenoid 
space. The regions next most frequently attacked are the arytenoid 
cartilages and the false vocal cords. Tuberculous ulcers, with the ex- 
ception of those upon the glottis, are more frequently multiple than are 
syphilitic. They are either very superficial and yellowish in color, or 
deep with swollen edges, sometimes, especially in the interarytenoid 
space, with papillomatous mucous proliferations. Although not path- 
ognomonic (Gottstein), the latter form is in the highest degree char- 
acteristic of tuberculosis. Further, a pale edematous condition of the 
rest of the mucous membrane points to tuberculosis. The most im- 
portant factor is the discovery of tubercle bacilli in the sputum. These 
may come from the larynx or from the lungs, which latter are always, 
or almost always, the first to be attacked. 

Deep ulcerations may lead to perichondritis laryngea. The most 
frequent form is perichondritis arytaenoidea. Perichondritis causes a 
very marked swelling and redness, generally over quite a large area. 
It very easily passes from this condition of swelling or collateral edema 
into stenosis. If it ruptures into the larynx, then the necrotic pieces 
of cartilage will be coughed out, and sometimes, when examining with 
the laryngeal mirror, we see them lying detached. 

Scars are found in the larynx, as elsewhere, after heahng from loss 
of substance. Those that chiefly interest us are the syphilitic. These, 
more than others, are incHned to retract, and hence they not infre- 





FlG. i86. — Pedunculated fibroma upon the 
under surface of the left vocal cord ; position 
during inspiration (v. Ziemssen). 



^'m^^ i^ii"'' 



Fig. 187. — Epithelial carcinoma of the 
right vocal cord (v. Ziemssen). 



quently result in stenosis. We either find a partial adhesion of the 
vocal cords or extensive cicatricial adhesions of the true and false vocal 
cords, with a funnel-shaped narrowing downward, etc. It is generally 
impossible to form any conclusion from the scar as to the nature of 
the antecedent processes. Only this, further, is to be said, that most 
laryngologists now agree that tubercular ulcers may cicatrize. 

Excepting the syphilitic gummata, new foinnations in the larynx 
have only a local significance. Gummata are either solitary nodules 

^ See special works regarding them. 



I 



LAR YNG OSCOP V. 5 4 1 

or a group of individually small nodules, at first red in color, with a 
crinkled contour. They are inclined to break up rapidly, and then to 
be replaced by deep ulcers. 

The other new formations may be divided into benign and malig- 
nant. Of the former, very much the most frequent are the papilloma ; 
more rare are the fibromata. Both, but especially the latter, are gen- 
erally located upon the vocal cords. Papillomata are sometimes flat, 
wart-like, sometimes regular papules, often multiple, cauliflower-like. 
The fibromata are generally pedunculated ; the surface is usually 
smooth, while that of the papillomata is uneven or villous. All the 
other benign new formations (lipomata, cysts, etc.) are extremely rare. 

The mahgnant new formations are, in the great majority of cases, 
carcinomata. They, like the papillomata, generally develop from the 
vocal cords ; next in frequency, from the false vocal cords. They 
manifests great inclination to necrosis and ulceration. The differential 
diagnosis of carcinoma, so long as there is no ulceration, is to be made 
from papilloma, after the occurrence of ulceration from tuberculosis 
and syphilitic ulceration : generally this is not easy. For particulars, 
we must refer to special works. Sarcoma of the larynx is much more 
rare than carcinoma. 

In reference to the more unusual diseases of the larynx, like lupus 
and lepra, we refer to special works. 

Spasm of the vmscles of the larynx is not at all, or only exception- 
ally, observed with the laryngoscope. We here only mention phonic 
and inspiratory functional spasm of the glottis in adults. The former 
takes place at the instant when the effort at phonation is made, when 
a decided closure of the glottis takes place, as can be recognized 
with the laryngoscope ; on the contrary, in the latter the vocal 
cords close at the instant of inspiration, hence, at the time when 
they ought to separate. During expiration the glottis is normal, or 
almost normally open, in opposition to paralysis of the [crico-arytae- 
noidei] postici muscles,^ in which they are very close together during 
expiration also. 

As disturbances of coordination, both of these conditions will be 
understood from their analogy to the neuroses caused by certain occu- 
pations affecting the upper extremity (writer's cramp, etc.), and are to 
be accounted for by over-strain. 

Paralysis of the Muscles of the I/arynx. — Paralysis of all the 
Muscles that Close the Larynx (the crico-aryt^noideus lateralis, arytae- 
noideus transversalis, thyreo-arytsenoideus ext. et internus — all sup- 
plied by the recurrent nerve). During phonation the vocal cords 
do not come close together, but remain in the position of inspira- 
tion. Complete aphonia is thus produced. The paralysis is generally 
bilateral, and is almost always due to hysteria as a basis. Hence, it is 
often combined with anesthesia of the larynx. 

Paralysis of the Arytcenoideus Transversiis. — During phonation the 
most posterior portion of the glottis (the pars cartilaginea) does not 
close. As a result we have hoarseness, even to complete aphonia. It 
not infrequently occurs with acute laryngitis, (See Fig. 188.) 

Paralysis of the thyreo-arytcenoidetis intern., one or both sides, causes 

1 See below. 



542 



APPENDIX. 



imperfect closure of the glottis ; when both sides are paralyzed there is 
a very narrow, symmetrical oval fissure (see Fig. 189); with unilateral 





Fig. 188. — Paralysis of the arytaenoideus in 
acute laryngitis (v. Ziemssen). The poste- 
rior portion of the glottis remains open during 
phonation. 



Fig. 189. — Paralysis of both thyreo- 
arytasnoidei interni, resulting from acute 
laryngitis (v, Ziemssen). Position during 
phonation. 



paralysis, a correspondingly narrow, unsymmetrical fissure. It occurs 
in laryngitis, but, also, often in hysteria. 

Paralysis of the crico-arytcenoidei postici muscles, the openers of the 
glottis (recurrent nerve) ; posticus paralysis. The vocal cords in 
bilateral paralysis, during expiration, stand near together, and during 
inspiration still closer, sometimes in apposition ; phonation may be 
quite normal. Hence, there is inspiratory dyspnea, with inspiratory 
stridor. The dyspnea may increase until there is asphyxia. In 
unilateral posticus paralysis the paralyzed vocal cord is motionless and 
lies near the middle line, while upon the sound side there are normal 
motions. 

In its etiology, posticus paralysis is in many cases obscure. Some- 
times it forms the beginning of a bilateral recurrent paralysis ; in other 
cases it seems to have a muscular origin (gumma in the muscle, laryn- 
gitis with atrophy, etc.). 

Recurrent paralysis — that is, paralysis of all the muscles supplied 
by the recurrent nerve — causes the vocal cords to assume the so-called 
cadaver position — the position with reference to each other that they 
have during quiet breathing. In severe paralysis, the vocal cords are 
entirely stationary in this position. In incomplete paralysis, they still 
make slis'ht motions outward and also show an inclination to assume 




Fig. 190. — Bilateral complete posticus 
paralysis (paralysis of the crico-arytaenoidei 
postici, dilatation of glottis) at the moment 
of inspiration (v. Ziemssen). 




Fig. 191. — Position during inspiration 
in paralysis of the left vocal cord, or recur- 
rent conduction paralysis (v. Ziemssen). 
Position and immobility of the left vocal 
cord, as in the cadaver. 



the position of adduction, for which there is, as yet, no undisputed ex- 
planation. When the paralysis has continued for a long time the 
vocal cords become atrophied. 



RHINOSCOPY. 543 

Bilateral recurrent paralysis produces bilateral cadaver position of 
the vocal cords, and thus complete aphonia and inability to cough. 
This is caused by compression of both recurrent nerves from aneu- 
rysm of the aorta, carcinoma of the esophagus, and enlarged glands. 
It will be readily understood that this bilateral paralysis from periph- 
eral causes is much more rare than unilateral. Complete or incom- 
plete bilateral paralysis of the recurrent nerve has been observed with 
bulbar paralysis, tumors, softening of the medulla, and compression of 
the vagi after their exit from the medulla. 

Unilateral recurrent paralysis is much more frequent. It may be 
easilv overlooked, because the voice is often clear, although weak, for 
the reason that the sound vocal cord during phonation reaches beyond 
the middle line. The paralyzed vocal cord during quiet breathing 
assumes the cadaver position, the sound one the position of rest — 
that is, somewhat more widely abducted than the other. During 
phonation the necessary closure of the glottis takes place, because the 
healthy vocal cord overreaches ; but then the glottis is necessarily 
askew. Unilateral paralysis of the recurrent nerve is almost always 
due to compression of the nerve in the neck or as it passes into the 
thorax; this will be brought about by the same causes as bilateral 
peripheral recurrent paralysis. Thus, recurrent paralysis may be an 
important corroborative symptom of aneurysm, of carcinoma of the 
esophagus, or of any other kind of mediastinal tumor. When there 
is a suspicion of one of these conditions, we may almost regard a re- 
current paralysis as decisive ; at any rate, the existence of a recurrent 
paralysis has often given the first suggestion that led to a discovery of 
an aneurysm or of carcinoma of the esophagus. 

Paralysis of the tensor of the vocal cords (crico-thyreoidei muscles, 
superior laiyngeal nerve) is very seldom observed, and then it is 
always combined with anesthesia of the mucous membrane and paral- 
ysis of the epiglottis. It is a tolerably dangerous condition, because 
of the accompanying difficulty of swallowing and the risk of degluti- 
tion-pneumonia. The glottis, as viewed by the laryngoscope, is not 
exactly even, but wavy. In unilateral paralysis the normal vocal cord 
is somewhat higher than the paralyzed one. 

Paralysis of the tensor of the vocal cords takes place most fre- 
quently in diphtheria, but then it is always accompanied with paralysis 
of other muscles. 

2. RHINOSCOPY. 

This is divided into anterior and posterior rhinoscopy. For anterior 
rhinoscopy we employ the reflector fastened to a band around the fore- 
head, artificial light, a nasal speculum, and sometimes also a sound. 
Of the different nasal specula that of Jurasz is the simplest, but it re- 
quires both hands of the examiner, and hence occasionally it is neces- 
sary to use one of the complicated ones suggested by B. Frankel, 
Duplay, Kramer, and others. 

Anterior Rhinoscopy. — By this we see in the upright image the 
nasal septum, the lower and a part of the middle turbinated bone, 
together with the lower and middle nasal duct. The upper nasal duct 
and the upper turbinated bone are not visible. The nasal septum ex- 



544 



APPENDIX. 



hibits a radish-yellow, more or less vertical, wall, with a more or less 
smooth surface ; the turbinated bones are roundish convexities of a 
reddish color. In many cases we employ the sound in order to com- 
plete a diagnosis during illumination of the speculum. By the sound 
we ascertain the resistance, mobility or immobility of swellings, pro- 
jections, tumors, foreign bodies, and move aside projecting polypi, etc. 
The examination must often be preceded by a vigorous blowing of 
the nose, but only exceptionally is it necessary to use the nasal douche. 
Sometimes it is also necessary before using the sound to anesthetize 
the surface with cocain. This is accomplished by means of a very fine 
nasal sound armed with a pledget of cotton the size of a pea. This is 
dipped into a lO per cent, solution of cocain (of which, however, the 
total quantity employed must not exceed a few drops), and then the 
liquid is applied with gentle pressure on the different parts of the 
mucous membrane. The cocain not only acts as an anesthetic, but it 
also reduces the swelling. 




TVG 



Psph. 

Fig. 192. — The rhinoscopic picture (after Schech). 

S, septum narium, posterior nares with turbinated bones and nasal ducts ; WG, posterior surface of the 
soft palate; TE and Tw', entrance into the tubes, eminences at the entrance; /'i/, Z*^/^, plica salpingo- 
paiatina and salpingopharyngea ; Zt^, levator swelling ; RG, Rosenmiiller's fossa;. 



Posterior Rhinoscopy (Pharyngoscopy). — This is accomplished 
by a pharyngeal mirror illuminated by a reflector fastened on the fore- 
head [as in the former proceeding]. During the examination the 
tongue must be held down with a spatula. The warmed laryngeal 
mirror is not held in the middle line, as in laryngoscopy, but alter- 
nately in the vault of the right and left palatal arches. It is not easy 
to interpret correctly the image of the naso-pharyngeal cavity, with 
the turbinated bones and nasal ducts, the Eustachian entrance, Rosen- 
miiller's fossae, and the roof of the pharynx. The difficulty is in- 
creased by the fact that frequently we cannot get an image of the 
whole at one time, and that the form of the respective parts differs in 






OTOSCOPY. 545 

different individuals. For the rest, compare the accompanying illus- 
tration [Fig. 192], taken from the excellent work of Schech. 

In posterior rhinoscopy it may sometimes be necessary to palpate 
with the sound, and occasionally to palpate directly with the finger. 

What is to be noted in practising rhinoscopy has in part been 
alluded to in what has already been said regarding the nose and throat. 
The most essential points are : deformities of the bony frame, altera- 
tions in the mucous membrane (acute and chronic inflammations, ad- 
enoid vegetations, specific exanthemata, or plaques [mucous patches], 
lupous alterations, etc. ; ulcerations, enlargement of the erectile tissues 
of the nose, tumors of all sorts). Of course we cannot enter into 
details here. 

3. OTOSCOPY. 

For this there is required a hand mirror, perforated in the middle 
(after v. Troltsch ; also Tiirck's reflector, which for laryngoscopy 
lately is frequently supplied with means for putting in a handle so as to 
use it as a hand-mirror), and a set of metal ear-specula. The best 
source of light is diffuse daylight. If this cannot be had, any arti- 
ficial light may be employed. Direct intense sunlight cannot be used. 

Draw the ear backward and upward, and then insert the ear-specu- 
lum. Masses of secretion or of epidermis in the meatus externus, 
which interfere with the examination, may be carefully removed by 
means of an elongated pledget of cotton, or, if that does not suffice, by 
carefully washing it out with an ear-syringe and water or solution of 
borax at a temperature of 28° C. [82° F.]. Ear-pincers should only 
be used by practised hands. Other hindrances which stand in the way 
of an inspection of the ear-drum, or of the introduction of the ear-spec- 
ulum, belong to pathology (foreign bodies, inflammation, or furuncles, 
ulcerations, new formations, exostoses, etc.). 

If the obstacles mentioned are not present we may at once inspect 
the ear-drum by illuminating it with the mirror. It appears as a gray, 
or yellowish-gray, shining membrane, which upon closer examination 
reveals certain details.^ On the anterior upper part is seen a white 
shining protuberance, the short process of the hammer, projecting 
more or less distinctly. Backward and downward from this runs a 
narrow band, which is the handle of the hammer ; forward and down- 
ward from its lower end is to be seen a bright triangular figure : the 
triangular reflex of light, which is produced by light falling on the ear- 
drum, as the ear is here drawn in. Above the short process of the 
hammer, bounded by the anterior and posterior folds of the ear-drum, 
is the membrana Shrapnelli, a spot of special significance in many dis- 
eases of the ear-drum and of the middle ear. 

If the ear-drum is very much retracted or atrophied we occasionally 
see in the posterior superior quadrant the long leg of the anvil and the 
posterior leg of the stirrup. 

The pathological alterations recognizable by examination with the 
ear-speculum are the following : 

Anomalies of vaulting, and these are : retraction of the ear-drum 
(compare Fig. 194), recognized by the handle of the mallet appearing 

^ Compare Figs. 193 and 194. 
35 



546 



APPENDIX. 



to be drawn backward and inward and, by the latter circumstance, 
seeming to be shortened, a condition often caused by obstruction of 
the Eustachian tube by adenoid growths in the throat ; also by scars, 
coalescence with the inner wall of the cavum tympani ; bulging outward 





Fig. 193. — Normal right ear-drum 
(after Sarron). 



Fig. 194. — Retracted left ear-drum 
(after Sarron). 



of the ear-dru7n by mucous, serous, purulent exudations in the middle 
ear, by neoplasms, etc. in it. 

Ruptures and perforations of the ear-drum : they may vary from an 
extremely minute size, scarcely to be recognized, to complete destruc- 
tion of this membrane. Deposits of chalk, dulness, thickening of the 
ear-drum, are other changes. 

Exudations in the cavum tympani : these are not always easy to 
recognize. Sometimes the level line of the exudation may be distinctly 
seen, and it changes with the change of position of the body, unless 
the effusion is encapsulated. 

It remains to be mentioned that the diagnosis of coalescence of the 
ear-drum with the wall of the cavum tympani is best made by Siegel's 
pneumatic ear-speculum, or the simplified one suggested by Traut- 
mann. It consists of a funnel, the exterior opening of which is closed 
by a glass plate. It can be put into the meatus auditorius air-tight. It 
is connected by a rubber tube to a rubber ball, by which the air in the 
funnel and meatus auditorius can be exhausted. Through the glass 
plate we may watch with the reflector the behavior of the ear-drum as 
the pressure in the meatus auditorius diminishes. When the coales- 
cence is extensive it does not project forward at all, but with partial 
adhesion it projects somewhat. 

As regards all special details we refer to special works upon dis- 
eases of the ear. 



4. OPHTHALMOSCOPY, 

This method of examination strictly belongs in the province of 
ophthalmology. Therefore we limit ourselves simply to its use for the 
purpose of diagnosis, where we observe a connection between certain 
changes of the fundus oculi and an internal disease. 

{a) Changes in the Fundus Oculi in Nervous Diseases. — 
All diseases which lead to a general increase of the intracranial press- 
ure may cause choked disk [neuritis optica). It is then always bilateral. 
At the same time choked disk may possibly be absent in all these con- 
ditions, but its presence is of the highest diagnostic significance, par- 



t 



OPHTHALMOSCOPY. 54/ 

ticularly in tumors and meningitis. Hydrocephalus is more rarely, 
and abscess of the brain very rarely, combined with choked disk. Uni- 
lateral choked disk is only caused by local pressure (a tumor, etc.) 
upon one optic nerve. 

The extent to which vision is disturbed when we have choked 
disk varies very much ; there may be none, or almost none. Disturb- 
ance of vision in choked disk usually occurs very early and markedly 
if the disease-process causes pressure upon the chiasm or the begin- 
ning- of the optic nerve, as in tumors of the hypophysis cerebri, or, if 
there is hydrocephalus which presses inward upon the third ventricle 
(Wernicke). There must, of course, be disturbance of vision if the 
choked disk is followed by atrophy. 

Pronounced choked disk is very easily recognized, yet it might be 
confounded with neuro-retinitis Brightii, which is exceptionally very 
much like it; but the exact recognition of a slight neuritis optica is 
very difficult. Whenever there is such a possibility an ophthalmologist 
should always be called in. 

It seems that neuro-retinitis is particularly apt to be present in 
meningitis when there is a basilar exudation ; it is also said to occur 
with encephalitis. 

Primary atrophy of the optic 7ierve takes place (by the intraocular 
portion of the nerve changing into a white disk with a sharp bound- 
ary) especially in tabes, sometimes in multiple sclerosis, dementia 
paralytica ; lastly, it occurs from pressure upon the chiasm. [The 
capillary circulation ceases, and hence the disappearance of the normal 
rosy hue.] 

Finally, it is to be mentioned that retinal apoplexy has been ob- 
served as the forerunner of cerebral hemorrhage, emboli of the cen- 
tral retinal artery as the precursor of cerebral embolism. Regarding 
the changes of the fundus oculi in syphilis, see below. 

We hardly ever find choroidal tubercle in tubercular meningitis. 
But it might occur with acute general miliary tuberculosis.^ 

(b) Changes in the Fundus Oculi in Other Internal Dis- 
eases. — Retinitis or neuro-retinitis albiuninnrica, with white specks, 
often arranged as radiating, sometimes confluent, lines around the mac- 
ula, thickening of the walls of the vessels and hemorrhages, occurs 
particularly frequently in contracted kidney, also often in subchronic 
and chronic nephritis, but very seldom in acute nephritis. The dis- 
turbance of vision is greater or less according as the macula is attacked 
or not. Uremic amaurosis has nothing to do with this condition, but 
as a matter of fact this form of retinitis often occurs in uremia (and 
this is important for the diagnosis of this condition). 

In constitutional syphilis (hence also in syphilis of the brain) we 
sometimes observe syphilitic changes in the fundus oculi : retinitis 
syphilitica, retinitis pigmentosa, choroiditis syphilitica. 

We not infrequently find tubercle of the choroid in acute general 
tuberculosis, especially in the region of the macula ; the tubercular 
deposits are generally very difficult to see. 

In diabetes there occurs a peculiar so-called diabetic neuro-retinitis 
and atrophy ; in leukemia, hemorrhages and whitish exudate ; in per- 

1 See below. 



548 APPENDIX. 

nicious anemia, but also in simple, severe anemia, licmorrJiages (gen- 
erally easily seen). 

Further, retinal ]icino7'7'Jiagcs are not unimportant diagnostic signs 
of pyemia, particularly pyemic endocarditis. They are not an abso- 
lutely fatal sign, as I myself saw in one case of puerperal pyemia : 
this undoubted case of pyemia, where besides the hemorrhages there 
were chills and slight icterus, recovered and the effused blood disap- 
peared, leaving clear specks behind. 

We have still to mention : 

Pulsation of the retinal arteries in aortic insufiFiciency, embohis of 
the central artery in endocarditis (also frequently observed in chorea) ; 
lastly, after severe hemorrhages (particularly of the stomach, also of 
the intestine, and uterus) there occurs sudden amaurosis, not infre- 
quently at first without any ophthalmoscopic conditions, afterward 
usually with distinct atrophy of the optic nerve. 

Alcoholic amblyopia shows a negative condition, or else hyperemia, 
neuritis, atrophy; tobacco amblyopia shows a normal fundus oculi, or 
atrophy ; in amblyopia or amaurosis saturnina either there is nothing, 
or else there is hyperemia and neuritic atrophy. 



5. BACTERIA WHICH COflE UNDER CONSIDERATION IN THE 
DIAGNOSIS OF INTERNAL DISEASES. 

The object of the following sections is to summarize the notable 
pecuHarities of the different micro-organisms which have already been 
mentioned in different parts of the work. But this pertains not only 
to the characteristics of the different organisms and their appearances 
when stained, but also to the much more important phenomena of their 
growth in cultures and under animal experimentation. In regard to the 
methods of procedure we must refer to the text-books upon bacteriol- 
ogy, and particularly to the instruction in the bacteriological courses. 

Staphylococcus Pyogenes. — This consists of small round cells 
which are usually found in irregular masses, but are never arranged in 
chains. The spores of this, as of all other micrococci, have not yet been 
discovered. It grows upon gelatin even without much air, in the temper- 
ature of the room, still more rapidly and luxuriantly in a higher temper- 
ature. The gelatin becomes liquefied. Scratch cultures are either gold- 
yellow (Staph, pyogen. aureus), or white (Staph, pyogen. albus), or clear 
yellow (cereus), or citron yellow (citreus). Upon a surface it grows in 
round, light-brownish colonies looking like dots, which lose their sharp 
contour in the center of the fluid. Mice, guinea-pigs, and rabbits die 
in from two to nine days after intravenous and peritoneal injections. 
Mice are killed with certainty only after the subcutaneous injection of 
a large amount, but none of the other animals named are killed by 
subcutaneous inoculation. 

It can be stained by all of the anilin stains, also by Gram's method, 
// is the most commo7i excitor of suppuration. It is found in abscesses, 
furuncles, in many cases of empyema, purulent peritonitis ; also in 
ulcerative endocarditis, etc., upon the valves of the heart ; in pyemia 
and acute osteo-myelitis, in the suppuration which complicates typhoid 
fever, also exceptionally in erysipelas, etc. 



BACTERIA AND DIAGNOSIS OF INTERNAL DISEASES. 549 

Streptococcus Pyogenes. — This resembles the first named by 
its round cells, which form chains by progressive portions pushing out 
in the same direction, which sometimes twist around each other. The 
separate cells often vary in size. It grows slowly upon gelatin, better 
upon agar, in the temperature of the room, but more rapidly in an in- 
cubator at a temperature of 27° C. [ = 80.6° F.]. It does not render 
gelatin fluid. The cultures upon a plate are extremely small, \ mm. 
diameter, yellowish to yellowish-brown in color. When inoculated by 
puncture it develops slowly and does not spread out upon the surface 
of gelatin. It is stained like the preceding. It is fatal to animals only 
when they have been previously weakened ; it causes redness and 
swelling of the rabbit's ear. There is frequently found a pus coccus 
which particularly inhabits the lymph tracts, and causes progressive 
phlegmon ; it is also found in pyemia, especially puerperal pyemia, 
likewise frequently in endocarditis. 

Streptococcus Brysipelatos.— Morphologically and as regards 
its staining qualities, it is Hke the preceding, but from the culture has 
thus far not with certainty been distinguished from it. In the rabbit's 
ear it causes a somewhat less active and extensive inflammation than 
the streptococcus pyogenes. The inflammation has the symptoms of 
erysipelas. Recently the opinion has become more and more prevalent 
that it is identical with the streptococcus pyogenes. 

Micrococcus gonorrhoeae (gonococcus, compare Fig. 145, page 
385). This usually occurs in the form of diplococci (roll-form), which 
often appear as tetracocci in that the single coccus has a bright stripe, 
as the beginning of a new portion. Culture of the gonococcus is some- 
what difficult ; until a short time ago it did not succeed at all. Bumm 
has cultivated the gonococcus upon coagulated blood serum in a moist 
chamber at a temperature of 32° C. [= 90° F.], and Gebhardt has bred 
it upon human blood serum ; but the safest method is that suggested by 
Wertheim, who employs placental blood serum (or cyst fluid, ascites 
fluid) and meat-peptone-agar. Upon these and also upon agar to 
which has been added sterilized albuminous urine they grow vigor- 
ously from the pus of male gonorrhea ; but in gonorrhea of the female 
culture is veiy difficult. However, culture is not requisite for diagnosis ; 
we must even say that it by no means offers any greater security than 
the simple microscopic examination, because with culture mistakes 
may happen, and because the vaccination experiment has hitherto failed 
with animals, but upon men it could only exceptionally be permitted, 
and then only for scientific purposes. 

Staining. — It is stained with all the anilin dyes, but best with Lof- 
fler's potassium-methylene-blue with heat ; but the degree with which 
it takes the stain varies very remarkably. It is completely unstained 
by the Gram method. Cocci of the form and size of the gonococcus 
and contained within pus-corpuscles may be positively declared to be 
gonococci. If contained in epithelial cells they do not prove anything 
atall.^ ^ 

Bacillus anthracis (see Fig. 90, page 246) is a rod, on an average 
about 5-10/i long, 1-1.25/i wide, with an abrupt end, often somewhat 
concave, with the inclination to develop into threads, without peculiar 

1 Compare Fig. 145, p. 385. 



550 APPENDIX. 

motion. It develops upon gelatin, potatoes, in alkaline urine at the 
ordinary temperature of the room, better at 36° C. \= 96,8° F.]. Some- 
times there develop spores within spores (endogenous formation of 
spores). Gelatin is rendered fluid ; when the amount of air is limited 
it develops poorly. Plate cultures, after twenty-four hours, can be seen, 
when sHghtly magnified, as round grayish-black spots, or wavy, as if 
curled ; upon potatoes the cultures are gray-white, somewhat elevated. 
It is fatal to susceptible nursing animals (mice, rabbits, guinea-pigs, 
certain kinds of sheep), even with the most minute inoculation and in 
a very short time. They are found in capillary blood and in all organs 
richly supplied with blood, particularly the spleen ; with living bodies 
they do not develop spores, likewise usually no long threads. They 
are stained by all basic anilin coloring-matters, but they are easily 
spoiled or become unclear if the covering-glass is made too hot ; they 
become non-transparent if too strongly stained. They can also be 
stained by Gram's method. 

Bacilli of malignant edema are 3-3.5/^ long, i-i.i/^wide(Flugge), 
hence thinner and shorter than the anthrax bacilli, from which they 
are also distinguished by the rounded ends. They form rigid threads, 
often of considerable length. The individual bacillus forms spores, 
and these are so large that they distend the bacillus. In the de- 
pendent drops they manifest peculiar motions. They only grow when 
oxygen is excluded, hence are anerobia. They develop in a reagent- 
glass, best in gelatin to which is added a one or two per cent, solution 
of grape-sugar (Fliigge). They flourish best at the temperature of the 
body. But they only grow at the lower end of a deep, very fine canal 
formed by sticking in a needle, and this canal is to be again closed. It 
fluidizes the gelatin and forms an offcnsive-smellmg gas. It is stained 
by all the anilin dyes, but poorly after the Gram method. It is found 
in garden soil, in muddy water, in the blood of asphyxiated animals, 
etc. A little of the soil taken up on the point of a penknife and put 
under the skin of the abdomen of a guinea-pig or rabbit generally kills 
it in one to two days by the invasion of the baciUi (but sometimes, 
during this experiment, tetanus develops). In man it causes edema 
and sometimes emphysema of the skin (see page 50). 

Typhus abdominalis bacilli (see Fig. 134, page 351) [bacilli of 
typhoid fever] are short, slender rods with rounded ends, thrice as long 
as broad, one-third as long as the diameter of a red blood-corpuscle. 
They have active motions (hanging drops). They form threads in cul- 
tures and hanging drops, but not in living animal bodies. It is question- 
able whether they form spores. They develop, at the temperature of the 
room, upon gelatin, agar, without the character of the growth being 
characteristic. The culture upon potatoes or upon potato-gelatin shows 
important peculiarities (Holz) : for some days after the inoculation it 
would seem as if nothing had grown — at most that the surface of the 
potato around the inoculating scratches has a moist shimmer ; in the 
whole circumference of this shimmer a very thick resisting turf of 
bacilli is present. This characteristic inconspicuousness for the unas- 
sisted eye of a well developed culture is not always present. And this 
bacillus cannot yet be positively distinguished from the bacillus coli 
notwithstanding the most varied morphological and biological, also 



BACTERIA AND DIAGNOSIS OF INTERNAL DISEASES. 55 I 

biochemical characteristic criteria have been employed. The typhoid 
bacillus is best stained with carbol-fuchsin or Loffler's alkaline meth- 
ylene-blue solution ; Mt is to be washed only with water. It is discolored 
after Gram's method. It regularly occurs in the intestine, spleen, 
liver, kidneys, also in the stools, from which, however, it cannot 
always be freed, in the urine, and now and then in the blood in abdom- 
inal typhus [typhoid fever]. 

Widal's Reaction. — The typhoid bacillus has the extremely important 
peculiarity that, bred in bouillon culture, after the addition of a minute 
quantity of blood-serum from a patient ill with typhoid fever, or conva- 
lescent from it, within a few seconds it loses its peculiar movements 
and collects into heaps, lines, and gradually also into lumps which, if 
examined in hanging drops, are visible to the naked eye. The blood- 
serum of healthy persons, or of persons suffering from any other disease, 
does not have this effect upon the typhoid culture. 

It seems that this highly interesting reaction has an extraordinary 
significance for the diagnosis of present or past typhoid fever. The 
reaction can be made with a few drops of blood taken from the skin.^ 

Colon Bacilli (Bacterium coli commune).'^ — This is a constant 
inhabitant of the intestinal canal from the first hours of extra-uterine 
life. It is a bacterium distinguished by varying morphological and 
biological behavior, and particularly by varying virulence. It occurs 
in intestinal catarrhs often in great quantities, even in pure cultures 
like the cholera bacillus, and is then very virulent for animals. It also 
occurs in the most varied parts of the body, particularly in the abdom- 
inal organs (peritoneum, gall-bladder, bladder, and renal basin), and 
there excites different degrees of inflammation. It shows a great simi- 
larity to the typhoid bacillus, with which many think it is identical. 
It is stained like that bacillus, and is easily bred upon gelatin. 

Diphtheria Bacilli^ (Loffler). — They are plump, partly curved 
small rods, distinguished by peculiar granules and curious club-shaped 
swellings at their ends. They do not thrive below 22° C. [71.6° F.], 
and they perish at 60° C. [140° F.]. The culture material hitherto 
used is generally the following mixture : 3 parts of blood-serum, i 
part of bouillon to which is added 1 per cent, of peptone, i per cent, 
of grape-sugar, and 0.5 per cent, of common salt. Deyke, however, 
has suggested a preferable alkali-albuminate-agar, which contains i 
per cent, of alkali-albuminate, i per cent, of peptone, 0.5 per cent, of 
common salt, ij to 2 per cent, of agar, and 5 per cent, of glycerin, and 
is exactly neutralized with pure HCl solution, then alkalized with i 
per cent, of a 33 per cent, solution of soda, the latter being added after 
the mixture has been filtered through cotton. It is best to place small 
pieces of membrane upon recently coagulated plates of Deyke's-agar.^ 
Diphtheria bacilli morphologically resemble a great many other bacilli 

1 30 c.cm. of concentrated alcoholic solution of methylene-blue, 100 c.cm. of o.i per cent, 
solution of potassium hydrate. 

2 See also p. 247. ^ Compare p. 352. * Compare Fig. 96, p. 261. 

5 Note in correction of the text : It is necessary to state that B. Frankel, in a publication 
which has just appeared (Deutsche Vierteljahrsschr. f. off. Gensundh. — Pflege, 1897). " Uber 
d. Bekampfung der Diphtheric " recognizes as alone adapted to the purpose Loffler's sugar- 
serum and Tochtermann's serum-agar. We have had excellent results in over 300 cases with 
Deyke-agar. 



552 APPENDIX. 

(pseudo-bacilli of diphtheria — Hoffmann, xerose-bacilli — Ernst and 
others), but they are often safely to be recognized in the diphtheria 
membrane by their great quantities and peculiar arrangement.^ These 
occur in the pseudo-membranes of diphtheria patients (constantly), and 
in their oldest parts, which are abundantly infiltrated with cells, never 
in internal organs. They have been found in the mouth in children 
after recovery from diphtheria and also exceptionally in healthy people. 
They are absent in scarlet-fever-diphtheria, in which, on the contrary, 
a chain coccus is found, if there is no mixed infection with bacillary 
diphtheria. It is pathogenic for rabbits, guinea-pigs, pigeons, and 
chickens ; when introduced into the trachea they cause pseudo-mem- 
brane ; in guinea-pigs if introduced under the abdominal skin other 
characteristic phenomena and generally death in four days. They are 
well stained with Loffler's methylene-blue and after Gram's method. 

Influenza Bacillus (R. Pfeiffer). — This is a very small bacillus, 
difficult to stain, which appears in the sputum of influenza patients in 
great quantities, arranged in nests and often lying together by twos. 
They seem to be the exciters of influenza, since they regularly appear 
in this disease, and often as almost the only micro-organism in the 
sputum. They are stained with difficulty. Cover-glass preparations 
are laid for five to ten minutes upon a pale-red watery dilution of 
carbol-fuchsin. Culture is difficult upon nutrient material containing 
hemoglobin. 

Tubercle bacilli (compare Fig. 52, page 159, and Fig. 144, page 
384) are thin rods, i.5-3.5/->« long (Fliigge), frequently shghtly curved 
or somewhat broken ; they often form threads, and sometimes two or 
more He closely together. Very often they contain a number of egg- 
shaped spaces (spores ?), and then, when stained and slightly magni- 
fied, they sometimes look like chain micrococci. They have no inde- 
pendent motion. They grow best in a reagent-glass upon an oblique 
coagulated, sterilized blood-serum and glycerin-agar, at a temperature 
o^ 37-5° C. [100° F.] (min. 30, max. 42). At best they grow very slowly, 
and hence precautionary measures are necessary that it may not de- 
velop excessively.^ In fourteen days there appear small, dull-white scales 
and specks, which, when slightly magnified, show an arrangement that 
reminds one of a tangled braid of hair.^ We can have it develop upon 
a covering-glass and then stain it by the method described on page 
248. [See also Methods of Staining described on page 160 jf!] 
The experiment of inoculation is best made upon guinea-pigs, by 
placing some sputum, for instance, in the abdominal cavity. Gen- 
erally, there is no reaction in the peritoneum. After two or three 
weeks the glands swell, and in four to eight weeks the animal dies. 

I/Cpra bacilli resemble small tubercle bacilli, and are stained with 
anilin in the usual way, but also like tubercle bacilli ; hence, like the 
former, there may be a double staining. They are found in leprous 
skin, in the glands, in the tissue-juices, in the nerves, also said to be 
found in the blood, etc. ; they occur mostly in small and large cells 
resembling giant-cells. Cultures have not yet been successfully made. 

Anthrax bacilli are like tubercle bacilli, only somewhat broader. 

^ See Frankel's publication referred to above. "^ For the technique, see special works. 
^ Compare Fig. 144, p. 384. 



BACTERIA AND DIAGNOSIS OF INTERNAL DISEASES. 553 

They are stained with Loffler's potassic methylene-bhie. Stain very 
carefully, then wash with dilute acetic acid. They are often easier 
and more certainly demonstrated by culture than by animal experi- 
mentation. They develop rapidly upon slices of potato at 35° C. 
[=^95^ F.], as a brownish, slimy mass. It can be inoculated upon 
guinea-pigs ; some maintain that puppies are better. Death follows 
after an indefinite time, and nodules occur in various organs (one of 
the first symptoms is a sweUing of the testicles). 

The cholera bacillus ^ has been very fully described upon page 
350/. It has there been pointed out that the certain proof is only made 
by culture. A mucous floccule from the stools or from the linen is 
taken, and is used for plate culture, either at once, or after enrichment 
of the possible cholera vibriones. The latter procedure is rather to 
be recommended. 

By *' enrichment " is understood the production of a luxurious 
growth of cholera bacilli on the surface of a fluid nourishing solution. 
This facilitates and accelerates the diagnosis of cholera. The flock of 
mucus is placed in a Dunham's solution of peptone. This solution 
consists of a sterilized solution of I per cent, peptone, 0.5 per cent, of 
common salt, of a strongly alkaline reaction. After six hours, kept at 
a temperature of 37° C. [98.6° F.] there is a pronounced turbidness of 
the upper stratum of the liquid which is produced by a pure culture of 
the cholera bacillus (" membrane formation"). In most cases practised 
observers will be tolerably certain in regard to the matter ; but absolute 
certainty is only attained by making plate cultures from this membrane. 
Agar plates at 37° C. require 8 to 10 hours; gelatin plates (5 to 10 
per cent, culture gelatin) which can be kept only at 22° C. [71.6° F.] 
require one to two days ; small white points are seen in the depth, 
which gradually come to the surface, and by liquefaction of the gelatin 
in the depth produce deep funnel-shaped depressions. At the bottom 
of the funnel there are white cultures no larger than the head of a pin. 
The infecting puncture made into gelatin in a test-tube un(;iergoes a 
change as follows : a funnel appears here also, which in its upper part 
contains a large air-bubble formed by the rapid evaporation of the 
fluidized gelatin. The lower portion of the puncture resembles a thin 
thread which, in places, looks clear like glass, like an empty capillary 
tube, while at other places the cumulated, sunken culture appears as 
gray or whitish threads. In the hanging drop very lively movements, 
like a swarm of gnats, are seen. The bacilli show a predilection for 
the edge. Larger plate cultures, if slightly magnified, show a peculiar 
luster and arrangement as if they were composed of broken glass. 
How to transmit them: i. Intra-peritoneal infection of guinea-pigs, 
according to R. Koch, will give a perfectly characteristic picture of 
the disease. 2. The inoculation is made upon guinea-pigs whose 
stomach-contents are made alkaline by 5 c.cm. of a 5 per cent, solution 
of soda (using an esophageal catheter) ; the intestine is made quiet 
by injecting into the peritoneum i c.cm. tinct. opium for each 200 
grams weight [of the animal] ; then, by means of the esophageal 
catheter, there is introduced lO c.cm. of the deposit of the cholera 
bacilli in bouillon. After two days the animal dies (often without 

1 See Figs. 130-132, pp. 35o> 351- 



554 APPENDIX. 

diarrhea, always without vomiting) : the condition of the intestines is 
found to be exactly Hke that in cholera. In the intestines are abun- 
dant cholera bacilli. 

TJie Cholera Reaction (Nitrozo-indol-reaction). — Recently this has 
again come into notice as a means of diagnosing cholera, but it does 
not seem to have an independent diagnostic value. 

Bacilli of Finkler-Prior (see Fig. 133, page 351) resemble 
cholera bacilH, but are thicker and plumper ; but in the colored prepa- 
rations they cannot certainly be distinguished from Koch's comma 
bacillus. Plate cultures develop remarkably rapidly, and render gelatin 
fluid in much larger quantity than cholera bacilH. This difference in 
the rapidity of development is the best mark of distinction. When 
slightly magnified, the cultures seem to be very finely and uniformly 
granular, of a yellowish-brown color. The inoculation-puncture, like- 
wise, shows a much more rapid fluidization, but not the clear threads 
beneath the upper *' air-bubble," but an irregularly wide channel, which 
reminds one of a stocking. After a week the whole test-tube becomes 
fluid. Also, the inoculation of animals give a different result— stinking 
intestinal contents, while in cholera they smell stale. 

Bacillus Bnteritidis. — This was found by Gartner in Franken- 
hausen in cases of meat-poisoning, and later by others (Karlinski). It 
is probably a frequent exciter of meat-poisoning ; possibly it may be 
the only exciter. It is a short, thick little rod, surrounded by an 
areole, which grows best upon nutrient gelatin. The cultures have 
a light-gray, coarsely granulated, transparent appearance, and do not 
liquefy. It has been found in the spleen of a person who died from 
poisoning, and in the meat which had caused the poisoning (Gartner), 
in the stool and vomit of another case (Karlinski), but it has also been 
found in the intestinal contents of healthy persons. Raw meat had a 
more poisonous effect, but cooked meat also in part caused sickness. 
If introduced subcutaneously, the bacillus caused death to mice, rab- 
bits, guinea-pigs. 

The bacillus enteritidis is stained by all the anilin dyes. In stain- 
ing the coloring matter Hes in the middle ; the ends of the bacillus are 
free from stain. 



INDEX 



Abdomen, diminished volume of, 278 
distention of, circumscribed, 278, 282 

in disease of peritoneum, 281 
drawing in of, 278 

scaphoid, 279 
fluctuation of, 283 
increase of dimensions of, 278 
inspection of, in diseases of peritoneum, 

281 
measuring circumference of, 283 
puncture of, to draw off ascitic fluid, 285 
scaphoid, 279 
sound on percussing, 97 
topography of, 268 
Abdominal breathing, 74 

disappears in paralysis of diaphragm, 80 
contents, position of, illustrated, 269 
disease, headache with, 447 

retardation of pulse in, 204 
distention, effect on manner of breathing, 

282 
inflammation restricts action of diaphragm, 

80 
muscles, paralysis of,. 495 
pressure, function of, 496 
reflexes, 458 

reflex, increase of, in intercostal neuralgia, 
458 
unilateral absence of, 533 
swellings, sensation of resistance over, 102 
typhus. See Typhoid fever. 
wall in emphysema, 75 
Abelmann on effect of extirpation of pancreas 
on fat-digestion, 348 
on resorption of food in amyloid degenera- 
tion, 335 
Abnormal constituents of urine, 393 

sound over lungs, 109 
Abscess, deep, shown by edema, 48 
due to dentition, 254 
irregular enlargement of liver from, 289 
of abdominal wall, pain from, 278 

simulating meteorism, 278 
of anus, pain at stools in, 335 
of brain, choked disk in, 547 < 
of chest- wall, weakened vocal fremitus 

with, 134 
of liver, fluctuation of, 292 
surface of organ in, 292 
tenderness in, 290 
of lungs, effect of, on thorax, 78 
elastic fibers in sputum of, 152 
hematoidin in sputum in, 147 
lung-tissue in sputum in, 147 



Abscess of lungs, purulent sputum in, 145 

of spleen, enlargement of organ in, 298 
tenderness in, 298 

of tonsil, 259 

peptonuria with, 398 

perinephritic, detection of, 357 

retropharyngeal, cyanosis in, 38 
detection of, 260 

subphrenic, 284 
Abscesses, peptonuria in, 398 

staphylococcus pyogenes in, 548 
Absolute deadness, 96 

galvanometer, 465 
Absolutely deadened sound, 96 
Absorption by stomach, 307 
Abulia, 439 

Accidental blood-murmurs, 197 (note) 
Accommodation in breathing, 85 

of valvular deficiency, 169 

paralysis of, 515 
Aceto-acetic acid in urine, 373 
Acetone in urine, 409 
odor of, 373 
with diaceturia, 407 
test for, 409 
Acetonuria, 409 

Achorion Schonleinii in vomit, 332 
Achroodextrin from starch, 304 

test for, 321, 322 
Acid-curve of urine, 364 

-intoxication in diabetic coma, 408 
Acidity of urine, determination of, 373 
j Acids, salivation caused by, 256 
Acoustic amnesia, 506 

nerve, affections of, disturbance of hearing 
in, 523 
Acromegalia, 531 
Actinomyces, cause of suppurations in mouth, 

'257 

in pleural exudation, 138, 139 

in sputum, 150, T64 
Active spasm of muscles, 456 
Acuoxylon, value of, 120 
Acute exanthematous diseases, 44 
Addison's disease, bronze skin in, 43 
Adenoid growths in throat, drawing-in of ear- 
drum in, 546 
Afanassiew on secretion of bile-pigment in 

poisoning, 41 
After-sensibility, 443 
Ageusis, 524 
Agrammatismus, 513 
Agraphia, 506 

literal, 513 

555 



556 



INDEX. 



Agraphia, varieties of, 513 
with atactic aphasia, 507 
Air in peritoneal cavity, auscultation and per- 
cussion of, 285 
in peritoneum, causes diminished area of 

hver-dulness, 296 
-passages, stenosis of, diminished inspira- 
tory pressure in, 141 
swallowing of, 310 
Akataphasia, 513 
"Albumin curve," 396 

determination of, in pleural exudations, 139 
in cerebrospinal fluid, 435 
in serous sputum, 145 
in urine, 378, 393 
in health, 366 

qualitative tests for, 394-396 
rare forms of, 398 
quantitative test for, 396 
Albuminometer, 397 
Albuminous corpuscles in sputum, 164 
Albuminuria, 378 
cyclic, 394, 396 
genuine, when occurs, 394 
inosite with, 406 
peptone with, 398 
renal, casts in urine in, 380 

when occurs, 394 
retinitis with, 547 
transitory, 394 
Albumoses in urine, 398 
Albumosuria, 398 

Alcohol, absorption of, by stomach, 357 
-amblyopia, central scotoma in, 521 
immoderate use of, effect on disease, 21 
-paralysis, diminished irritability in, 485 
-poisoning, glycosuria in, 401 
headache in, 447 
odor from mouth in, 253 
use of, effect on disease, 21 
Alcoholic amblyopia, appearance of eye in, 
548 
stools, color of, 337 

odor of, 336 
tremor, 489 
Alcoholism, trembling of tongue in, 254 
Aldehoff on casts in urine of diabetic coma, 

380 
Alderton, recoil-theory of apex-beat, 172 
Alexia, 506 

Algosis faucium leptothricia, 263 
Alkalies, salivation produced by, 256 
Alkaline fermentation, odor of stools of, 336 
of urine from micro-organisms, 383 
reaction of urine in health, 364 
Allochiria, 443 

Amaurosis after severe hemorrhages, 548 
saturnina, ophthalmoscopic appearance of 

eye in, 548 
temporary partial, significance of, 522 
uremic, 547 
Amblyopia, alcoholic, appearance of eye in, 
548 
saturnina, appearance nf fundus in. 548 
tobacco-, appearance of fundus oculi in, 548 
Ammonia in urine in dialjetes, 408 
-poisoning, odor of vomit in, 332 



Ammoniacal fermentation of urine, 363 

stool, 336 
Ammoniaco-mkgnesian phosphate, crystals of, 
in feces of typhoid fever, 349 
in urine, 389 
Amnesia, acoustic, 506 
phenomena in, 508 
testing of, 509 
visual, 506 
Amnestic aphasia, 507, 508 
Amphoric breathing, 126 
Amphoteric reaction of urine, 365 
Amyl-nitrite poisoning, glycosuria in, 401 
Amyloid degeneration of gastric mucosa, an- 
acidity in, 325 
of intestine, poor resorption of fats in, 

335 
kidney, albuminuria in, 394 

hyaline casts in urine of, 380 
liver, increased consistence of, 292 

surface of, 291 
spleen, enlargement of, 298 
Amylolysis, disturbed, m superacidity of stom- 
ach, 325 
incomplete, shown by microscopical exam- 
ination of vomit, 331 
Amylolytic period of digestion, 305 
Amyotrophic lateral sclerosis, 454 

bladder disturbance absent in, 528 
increased tendon reflexes in, 461 
reaction of degeneration in, 484 
Anacidity of stomach, 309 

significance of, 325 
Analgesia, 443 
Anamnesis defined, 17 
form for recording, 26 
method of obtaining, 19 
what it comprises, 18, 20 
Anarthria, 502 
Anasarca, 46 

Anatomical diseases, symptoms of, 533 
Anchylostoma duodenale, 344 
Anchylostomiasis, 345 

Charcot's crystals in feces of, 349 
Anemia a cause of dropsy, 47 
albuminuria in, 394 
alteration of percentage of hemoglobin in, 

238 
ascending venous pulse in, 229 
caused by bothriocephalus latus, 343 
color of urine in, 369 
dicrotic pulse in, 213 
diminution of alkalescence of blood in, 250 

of red corpuscles in, 238 
dizziness in, 471 
frequent pulse in, 207 
gravis, blood-corpuscles in, 241 
headache in, 447 
heart-murmurs in, 197 
hemorrhages in fundus of eye in, 548 
leukocytosis in, 242 
local redness in, 38 
microcythemia in, 240 
oligocythemia in, 238 

pernicious, alteration in red corpuscles in, 
240 
leucin and tyrosin in urine of, 390 



INDEX. 



557 



Anemia, retinal hemorrhage in, 514 
uric acid increased in, 392 
poikilocytosis in, 241 
polyuria in, 366 

produced by anchylostoma duodenale, 345 
redness of face in, 37 
signification of the term, 231 
small pulse in, 209 
sounds over arteries in, 222 
splenic, enlargement of spleen in, 298 
strengthening of heart-sounds in, 187 
subjective sensibility of hearing in, 523 

sensations of vision in, 522 
syncope in, 438 
venous humming in, 230 
vertigo in, 438 
Anemic heart-murmurs, 97 

necrosis of pons and medulla, 422 
Anesthesia, 443 
cause of, 420 

of mucous membrane in hysteria, 458 
of pharynx, 527 
sensory, in gross hysteria, 491 
unilateral, 443 
Aneurysm, aortic, pulsation in heart-region in, 
176 
blood in sputum from rupture of, 144 
contraindicates use of stomach-sound, 313 
difficulty in distinguishing from apparent 

enlargement of heart, 181 
increase in size of chest in, 141 
neuralgia due to, 447 
of abdominal aorta, 219 
of aorta a cause of cyanosis, 'i^?> 

and other arteries, effect of, on pulse, 21 1 
crystals in sputum in hemorrhage into 

lungs from, 156 
cyanosis from, 38 
distinguished from empyema pulsans, 90, 

91 

phenomena in, 218, 219 

pressure by, upon recurrent nerve, 543 

pulse-curve in, 216 
of arch of aorta affects vessels of left side, 

219 
of ascending aorta affects vessels of right 

side, 219 
of descending aorta, 219 
of innominate artery, 219 
of minute arteries of brain, hemorrhage 

from, 526 
of pulmonary artery, 219 
pressing heart forward, 176 
pressure on nerves from, 436 
pulsation of, near stomach, 272 
simulates enlarged heart, 181 
small pulse in, 209 
Angina, coronary, bradycardia in, 204 
enlargement of tongue in, 254 
herpetica, 45 
lacunar, tonsils in, 258 
Ludovici a cause of cyanosis, 38 

pus in larynx from, 539 
Ludwigii, detection of, 255 
pectoris, bradycardia in, 204 

frequent pulse in, 207 
tonsils in, 258 



Angle, epigastric, 73 
of Louis, 73 

in emphysematous thorax, 75 
in phthisical thorax, 76 
Angulus Ludovici, 68, 73 
Anidrosis, 2)Z 

Anil in-poisoning, color of blood in, 233 
Animal parasites in sputum, 157 
in urine, 382 
of alimentary canal, 340 
Ankylostomiasis. See Anchylostomiasis. 
Ankylostomo-anemia, edema in, 48 
Anodal closure, result of, 467, 468 
Anomalies of respiration, 79 
Anorexia, 439 
Anosmia, 524 

Anterior gray columns, disease of, reaction of 
degeneration with, 484 
horn of cord, characteristic sign of paralysis 
above, 456 
excitability of, increases skin-reflex, 

458 
results of disease of, 454 
tendon reflexes decreased in disease of, 
461 
rhinoscopy, 543 
Anthrax bacilli, 552 

in blood, 246 
Anticipating intermittent fever, 63 
Antifebrin in urine, test for, 41 1 
Antimony in urine, 41 1 
Antiperistalsis of stomach, 272 
Antipyrin in urine, test for, 41 1 
Anuria, 367 

in hysteria, 528 
nervous, 368 
Anus, examination of, 280 

fissure of, pain at stools with, 335 
Anxiety, cause of disease, 21 
frequent pulse in, 207 
increases secretion of urine, 362 
mydriasis in, 517 
Aorta, anatomical relations of, 2l8 
aneurysm of, phenomena in, 218, 219 

pulse-tracing in, 216 
pulsation of, 218 
sclerosis of. See Sclerosis. 
stenosis of. See Stenosis. 

phenomena in, 219 
various phenomena of, 218 
Aortic aneurysm, pulsation In heart-region in, 
176 
heart-sound, second, strengthening of, 188 
insufficiency. See Insufficiency. 
stenosis. See Stenosis. 
effect of, 168 
Ape-hand, 499 
Apex-beat, alteration of width and strength 

of, 173 

cause of, 172 

disappearance of, 174 

displacement of, 172 

doubling of, 175 

examination of, 171 

strength and breadth of, a sign of hyper- 
trophy of left ventricle, 174 

weakening of, 174 



558 



INDEX. 



Apex-curve, 212 
Aphasia, 506 

amnestic, 507, 508 

atactic, 507 
causes of, 507 
phenomena of, 507 
testing for, 509 

ataxic, 506, 507 

Charcot's diagram of, 510 

graphic representation of, 509-5 13 

literal, 507 

motor, 507 

sensory, 506 
Aphasic disturbances, 503 
mode of testing, 509 
Aphemia, 507 
Aphonia, 67 

from recurrent paralysis, 543 

how caused, 541 

tone of cough in, 143 
Aphthae in vomit, 332 

Aplasia of lung, deadened sound over, 100 
Apnea in Cheyne-Stokes' respiration, 81 
Apoplectic habit predisposes to hemorrhage 

of brain, 525 
Apoplexia cerebri, glycosuria from, 402 
Apoplexy, albuminuria w^ith, 394 

coma from, 437 

decubitus after, 530 

irom tinnitus aurium, 523 

glycosuria vi^ith, 402 

imbecility from, 438 

pulse in, 210 
Apparatus for electrical examination, 462 
Appendicitis, pain on palpation of right iliac 

fossa in, 277 
Apple-odor of urine, 373 
Arbutin, color of urine after taking, 371 
Arc de ceixle, 434, 491 
Arhythm, 207 
Arm, motor-centre for, 416 

motor-points of, 470, 471 

muscles of, paralysis of, 498 
Aronsohn-Phillips's stain for neutrophile cells, 

.245 
Arsenic in urine, 411 

-paralysis, diminished irritability in, 485 

-poisoning, jaundice from, 42 
Arsenical melanosis, 43 
Arseniuretted hydrogen, poisoning by, causes 

hematohepatogenous icterus, 401 
Arterial liver-pulse, 228 

pressure, increased, polyuria in, 366 

sclerosis. See Sclerosis. 
Arteries, auscultation of, 221 

examination of, 201 

normal condition of, 221 

palpation of, 220 

pathological conditions of, auscultation of, 
222 

sclerosis of, a cause of hypertrophy of left 
ventricle, 170 
Arthritis deformans, pain in spine in, 447 
stiffness of spinal column in, 434 

Frankel's pneumococcus in, 163 
Arthropathiae in nervous diseases, 530 
Arytaenoideus transversus, paralysis of, 541 



Ascarides in ductus choledochus a cause of 

jaundice, 41 
Ascaris lumbricoides, 343 

eggs of, 345 
Ascites, 281 

absence of liver-dulness in, 296 
appearance of skin in, 282 
associated with cirrhosis of liver, 291 
chylous, 286 
diagnosis of, 281 
effect on form of chest, 77 
enlargement of veins of abdomen in, 282 
expansion of thorax in, 77 
from venous engorgement, 223 
that moves about, 282 
Asiatic cholera. See Cholera. 

vomit in, 328 
Aspergillus fumigatus in sputum, 149 

in sputum, 164 
Aspermatism, 412 

Asphyxia, local, in nervous diseases, 526 
Aspirated fluid, examination of, 139 
Aspiration emphysema, 49 
Associated movements, 492 
Asthma, bronchial, a cause of cyanosis, 38 
cause of emphysema of lung, 89 
Charcot-Leyden crystals in, 149, 157 
Curschmann's spirals in, 155 
expiratory dyspnea in, %^ 
frequent respiration in, 84 
spiral casts in, 149 
mucous threads in sputum of, 150 
oxalate of lime in sputum of, 157 
simulation of, 20 
spirals in sputum of, 150 
uremic, 399 
Atactic aphasia, 507 
causes of, 507 
phenomena of, 507 
testing for, 509 
Ataxia, 487 

disturbance of conception of motion in, 446 
handwriting in, 513 
how shown, 487 
of upper extremity, 513 
when it occurs, 488 
Ataxic aphasia, 506, 507 
Atelectatic crepitation, 131 
Atheroma of aorta, systolic murmurs with, 218 
of arteries, pulse-curve in, 214 
of blood-vessels, causes disease of vessels 
of brain, 526 
Athetosis, 492 

Atonic atrophic paralysis, 457 
degenerative paralysis, 419 
paralysis, 457 
Atony of stomach, symptoms in, 324 
Atrophic paralysis, 453 

fibrillary contractions in, 490 
Atrophy, acute yellow of liver, diminished 
urea in, 392 
diminution of phosphates of urine in, 

.392 
disappearance of liver, dulness in, 296 
leucin and tyrosin in urine of, 390 

and paralysis, parallelism between, 454,455 

circumscribed, 453 



INDEX. 



559 



Atrophy, degenerative, 453 
diffuse, 453 
puerile muscular, increased motility of 

spinal column in, 434 
muscular, from joint-disease, diminished 

irritability in, 485 
myopathic muscular, diminished irritability 

in, 484 
of inactivity, 453 
of muscles, 453 

of optic nerve, concentric narrowing of field 
of vision in, 521 
in tabes dorsalis, 513 
mydriasis with, 517 
primary, 547 
of paralyzed muscles as a symptom, 533 
of tongue, 494 
primary myopathic, 455 
progressive muscular, 454 

fibrillary contractions in, 490 
increased irritability in, 485 
spinal progressive muscular, decreased ten- 
don reflexes in, 461 
reaction of degeneration in, 479, 484 
Atropin, effect of, on pupil, 517 
-poisoning, red skin from, 37 
Attitude of patient, 28 
Auditory tx'act, 421 

Auenbrugger, the discoverer of percussion, 92 
Aura of epilepsy, 490 
Auriculotemporal nerve, distribution of, 448, 

449 
Ausculation, direct, 119 

indirect, 119 

mediate, 119 

methods of, 119 

of arteries, 221 

of heart, 182 

points of election for, 184 

of intestine, 281 

of lungs, 118 
history, 118 

of peritoneal cavity, 285 

of pulse, 221 

of stomach, 276 

of veins, 230 

of voice, 133 

when it may be omitted, 135 

of whispered voice, 135 

stethoscopic, 119 
Autocthonous thrombi, effect on pulse, 211 
Auto-intoxication with aceto-acetic acid, 407 

with acetone, 409 

by oxybutyric acid, 407, 40S 
Auxiliary muscles of respiration, 496 
Axillary artery, compression of, fulness of 

veins of arm in, 224 

lines, 69 

nerves, illustrated, 450 
Azoospermia, 412 

temporary, 413 

Baas and Penzoldt's explanation of puerile 

breathing, 122 
Baccelli's auscultation of the whispered voice, 

135 
Bacilli in blood, 245 



Bacilli in cerebro-spinal fluid, 435 
Bacillus anthracis, 549 

comma, in vomit of Asiatic cholera, 351 

enteritidis, 352, 554 

of anthrax, 552 

of Asiatic cholera in feces, 350 

of cholera, 553 

of diphtheria, 551 

of Finkler-Prior, 554 

of glanders in blood, 247 

of influenza, 552 

of lepra, 552 

of malignant edema, 550 

of tuberculosis, 552 
in blood, 246 
in feces, 353 

in pleural exudations, 138 
in sputum, 150, 159 

of typhoid fever, 351 

urea; in urine, 383 
Back, percussion of, 104 
Bacteria, casts of, in urine, 382 

diagnostic value of, 548 

in feces, 349 

in mouth-contents, 257 

in pleural exudations, examination for, 137 

in urine, 361 

in vomit, 332 

intestinal, in stools, 349 

of digestion, 305, 306 
Bacteriological examination of blood, 247 
Bacterium coli commune, 352, 551 

in urine, 383 

Finkler-Prior in feces, 352 
Balz on distoma pulmonum in sputum, 149, 

158 
Bamber, reference to, 166 
Band-l)ox note, 116 
Barrel-shaped crystals of uric acid in urine, 

^^^^ 
Bartels on wandering kidney, 357 

Basch (V.), sphygmomanometer, 210 

Base of brain, effect of lesions of, 427 

Basedow's disease, blowing murmur over 

thyroid glands in, 223 

frequent pulse in, 207 

hemidrosis in, 34 

palpitation and pain of heart in, 526 

sensations of heat in, 526 

strengthening of lieart-sounds in, 187 

strengthened heart-beat in, 174 

tremor in, 489 
Basilar artery, 421 
Basophile cells, staining of, 244 
Baths, cold, value of pulse in showing effect 

of, 218 
Baumann on relation between cystin and 

ptomains in urine, 390 
Beale on carbonate of lime in urine, 389 
Bencziii- and Jonas, determination of demar- 
cation of organs by surface tempera- 
ture, 91 
Benedict's symptom-complex, 427 
Berger, microbe of whooping-cough, 164 
/i-oxybutric acid in urine, 407 
Biceps-muscle, electrical stimulation of, 471 
Biceps-tendon reflex, 460 



560 



INDEX. 



Biedert's method of demonstrating tubercle 

bacilli in sputum, 161 
Bienstock, reference to, 349 
Biermer, reference to, as improver of per- 
cussion, 92 
on "band-box note" in emphysema of 
lungs, 116 
Biermer's change of sound, 1 17 
Biernacki on decrease of hydrochloric acid in 

nephritis, 324 
Bile-acids in urine, 400 
in health, 366 
coloring-matter in urine, 37 1 
deficiency of, absorption of fat in, 336 
diminished flow of, stools in, 337 
in stomach-contents, 315 
-pigment in sputum, 147 

in urine, 400 
vomiting of, 328 
Biliary colic, vomiting in, 326 

engorgement, tenderness of liver in, 290 
Bilious stools, 337 

vomit, 328 
Biot's respiration, 83 
Bismuth test for sugar in urine, 402 
Bitter almonds, poisoning by, odor of vomit 

in, 332 
Black-water fever, formations in blood of, 249 
Bladder, atony of, residual urine in, 368 
crises in tabes, 528 
distended, diagnosis of, 360 
disturbance of, points to palpable disease, 

533 
examination of, 360 

importance of emptying, in examining ab- 
dominal organs, 303 
paralysis of, 528 
position of, 360 
tenesmus of, 361 
" Bleating voice," 135 
Blood, abnormal additions to, 245 
alkalescence of, 250 
amount of, in body, 23 1 
anthrax bacilli in, 246 
bacilli in, 245 
casts in urine, 382 
chemical examination of, 250 
color of, 232 

in poisoning by different substances, 233 
coloring-matter of, in urine, 370 
consistency of, determination of, 236 
corpuscles, counting of, 238 
in feces, 348 
in urine, 375, 377 
in vomit, 331 

red, number of, in cubic millimeter of 
blood, 238 
normal size of, 240 
alteration of in malaria, 249 
alterations in number and appearance 

of, 238 
in size and form of, 240 
in sputum, 15 1 
staining of nuclei of, 241 
white, counting of, 244 
in salivn, 256 
in sputum, 151 



Blood-corpuscles, red, in stomach-contents, 
316 
m unne, 377, 378 

proportion of to red corpuscles, 242 
normal and pathological condition of, 
241-244 
determination of amount of hemoglobin in, 

233 
examination of, 231 
filaria sanguinis hominis in, 250 
glanders-bacillus in, 247 
icterus, 41 

in cerebrospinal fluid, 435 
in stomach-contents, 315 
in stools from hemorrhage of stomach, 

329 
in urine, appearance of, 375 
makes it turbid, 371 
microscopical examination of, 377 
reaction of urine ^^ith, 373 
in vomit, testing for, 330 
malarial parasites in, 247 
method of obtaining for examination, 232 
microscopic examination of, 237 
micro-organisms in, 245 
-pigment in urine, tests for, 400 
-preparation, dry, making of, 237 
making of, 237 
methods of drying, 244 
staining of, 244 
-pressure, reduced, anuria in, 268 
quickness of coagulation of, 250 
specific gravity of, determination of, 236 
spectroscopic examination of, 235 
spirillum recurrens in, 246 
-supply of brain, 421 
testing for, in vomit, 330 
tubercle bacilli in, 246 
typhoid bacillus in, 246 
uric acid in, 250 
vomiting of, 328, 329 
watery condition of, polyuria in, 366 
Bloody sputum, 145 
stools, 338 
vomit, 328, 329 
Blue disease, 38 

-red skin, 38 
Blushing, 37 
Boas on resorcin as a test for hydrochloric 

acid in stomach, 317 
Body, normal temperature of, 53 

temperature of, 50 
Boilliaud, reference to, 506 
Bone-conduction, testing of, 522 

-reflexes, 460 
Bones and joints, anomalies of, in nervous- 
diseases, 530 
arrest of growth of, after paralysis, 530 
brittleness of, in tabes, 530 
sound on percussion of, 96 
Borborygmi, 281 
Bernhardt on relation of weight of body to- 

height, 32 
Bothriocephalus Jatus, 342 
Boulimia, 439 

Boundaries of lungs, extension of, II7 
changed condition of, 117 



INDEX. 



561 



Bowels, disturbance of, from general venous 
engorgement, 224 

involuntary discharge of, 335 

non-tympanitic-. sound over, 99 

obstruction of, grass-green vomit in, 328 

tympanitic sound over, 98 
Brachial artery, auscultation of, 221 

plexus, paralysis of, 450 
Brachialis anticus, electric stimulation of, 

471 
Brachycephalus, 431 
Bradycardia, 203 

occurrence of, 284 
Brain-abscess, fever in, 57 

base of, effect of lesions of, 427 
blood-supply of, 421 

-disease, Cheyne-Stokes' respiration in, 82 
disturbance of consciousness in, 437 
retardation of pulse in, 204 
symptomatic convulsions in, 490 
topographical diagnosis of, 423 
organic diseases of, imbecility in, 438 
Braune on physiological accentuation of angle 

of Louis, 73 
Breath, odor of, 252 
Breathing, abdominal, 74 

disappearance of, from paralysis of dia- 
phragm, 80 
alteration of, in disease of larynx, 67 
amphoric, 126 

anomalies of, as regards pregnancy and 
rhythm, 81 
of manner of, 80 
asymmetry of, 80 
audible, 87 
bronchial, 121 
costal, 74 
diaphragmatic, 74 
difficult, 29, '^i 

failure of action of diaphragm in, 80 
metamorphosing, 127 
normal, 73 
obstructed, 67 
of compression, 126 
painful, effect of posture upon, 29 
puerile, 122 

thoracic, replaced by diaphragmatic, 80 
transition, 127 
undefined, 127 
vesicular, 121 
Brenner on electric examination of acoustic 

nerve, 522 
Brick-dust sediment in urine, 363, 387 
Brieger on connection between ptomains 

and cystin in urine, 390 
Bright's disease, dropsy with, 399 

edema in, 48 
Brittleness of bones in tabes, 530 
Broca's aphemia, 507 
Bromin in urine, test for, 410 
Bronchial asthma. See Asthma. 
from nasal affections, 525 
breathing, 121 

as a symptom of diseases, 125 
distinguishing of, from vesicular breath- 
ing, 123 
catarrh. See Catarrh. 

36 



Bronchical tubes, closure of, weakened vocal 

fremitus in, 134 
Bronchiectasis, aspergillus fumigatus in 
sputum of, 150 
friction-sound in, 133 
leptothrix granules in, 150 
I odor of sputum in, 147 

quantity of expectoration in, 144 
Bronchitis a cause of cyanosis, 38 
acute croupous, tube-casts in, 149 

mucous sputum in, 144 
alveolar epithelium in sputum of, 15 1 
capillary, non-uniform crepitation in, 132 
change of vesicular breathing in, 124 
Charcot-Leyden crystals in, 157 
chronic, leptothrix granules in, 150 
croupous, tube-casts in, 149 
Curschmann's spirals in, 155 
leptothrix buccalis in sputum of, 150 
croupous, Charcot-Leyden crystals in, 149 
cyanosis from, 43 
dry rales in, 129 

fetid, crystals of fatty acid in sputum of, 
156 
mucopurulent sputum in, 145 
odor of sputum in, 147 
tyrosin in sputum of, 157 
ferment in sputum of, 164 
frequent respiration in, 84 
inspiratory drawing-in of, 87 
jerking respiration in, 125 
moist rales in, 130 
prolonged expiration in, 124 
purulent, coin-shaped sputa in, 145 
vital capacity of lungs in, 141 
Bronchophony, 135 
Bronchoblennorrhea, quantity of expectoration 

in, 144 
Bronchus, stenosis of, effect of, 87 
Bronze skin, 43 
Bruit de pot fele, 116 
Bulbar dysartliria, 502 

paralysis a cause of cyanosis, 39 
absence of bone-reflexes in, 461 
absence of pharyngeal reflex on, 458 
cyanosis in, 39 
diminished irritability in, 485 
disturbance of speech in, 502 
increased secretion of saliva in, 527 
paralysis of diaphragm in, 80 
paralysis of recurrent nerve with, 543 
position of soft palate in, 494 
quickened pulse in, 526 
reaction of degeneration in, 484 
speech in, 502 
pulse, 227 
Bulbus jugularis, engorgement of, 225 
Bulging in neighborhood of heart, 175 
Bumm, method of cultivating micrococcus 

gonorrhosfe, 549 
Burns, hemoglobinuria after, 370 
'* Buzzing" felt near heart, 177 

Cachectic leukocytosis, 242 

Cachexia a cause of general atrophy, 454 

cancerous, oxaluria in, 389 

chronic, disturbed consciousness in, 437 



562 



INDEX. 



Cachexia, defined, 31 
delirium in, 438 
diminished urea in, 392 
fever in, 59 
indicanuria in, 369 
oxaluria in, 389 
paleness in, 36 
state of skin in, 32 
tuberculous, oxaluria in, 389 
Cachexias as a cause of atrophy, 454 
Cadaver position of vocal cords, 542 
Cadaveric odor of breath, 253 
Calculi in urine, 391 
phosphatic, 391 
urinary, residual urine in, 368 
testing of, 391 
Calculus, mulberry, 391 

renal, thickening and distention of ureters 
in, 360 
Callus, pressure on nerves by, 436 
Camman, stethoscope of, 120 
Cancer. See Carcinoma. 
-navel, upon liver, 292 
of stomach, tumors of, 273 
Cancrum oris, detection of, 255 
Cane-sugar, digestive changes in, 304 
Cantani on oxaluria, 389 
Cantharides poisoning, fibrin in urine of, 398 
Capillary pulse, 220 
Capsule, inner, lesion of, with hemichorea, 

492 
Caput medusae, 225 

quadratum, 430 
Carbolic acid, color of urine after taking, 371 
in urine, 41 1 

poisoning, odor of vomit in, 332 
Carbonate of lime in urine, 389 
Carbonic acid, absorption of, by stomach, 307 
inflation of stomach with, 271 
poisoning, glycosuria in, 401 
Carbonic-oxid poisoning, spectroscopic ap- 
pearance of blood in, 235 
Carcinoma, acetone in urine in, 409 
coma from, 437 
nutrition poor in, 525 
of esophagus, pressure by, upon recurrent 

nerve, 543 
of gall-bladder, tumor in, 292 
of kidney, palpation of, 358 , 

shreds of tissue in urine of, 379 
of larynx, 68, 541 
of liver, density of organ in, 292 
surface of liver in, 291 
tenderness in, 290 
of pancreas, palpation of, 302 
of peritoneum, 283 

of pleura, hemorrhagic exudation in, 139 
of skull, 431 

of spleen, surface of organ in, 298 
enlargement of organ in, 298 
of stomach, anacidity in, 325 
hypacidity in, 324 
hypersecretion in, 325 
white blood-cells in stomach-contents in, 
316 
of tougue, hardness of tongue in, 254 
ulcerating, odor of vomit in, 332 



Carcinoma ventriculi, bloody vomit in, 329 
peptonuria with, 398 

villosum of bladder, shreds of tissue in 
urine of, 379 
Carcinomatous coma, 437 

pleurisy, cells in exudate of, 137 
Cardia, stenosis of, detection of, 267 

of stomach, position of, 268 
Cardiography, 175 
Caries of teeth, foul odor from, 252 

of spine, stiffness of spinal column in, 434 
pain in spine in, 447 
sensitiveness of spine to pressure in, 434 
Cartoid artery, auscultation of, 221 
pulsation of, in health, 220 
left, importance of relation of, to aorta, 
423 
pul^e in aneurysm of aorta, 219 
Cartilage in sputum, 148 

sound on percussion of, 96 
Case-taking, value of, 25 
Caseous crumbs in urine, 379 
Casts, epithelial 382 
granular, 381 
hyaline, 380 
in urine, 379 

the infallible signs of nephritis, 378 
of bacteria in urine, 382 
of hemoglobin in urine, 382 
renal, kinds of, 380 

preparation of, for examination, 380 
waxy, 380 
Catalepsy, 492 
Cataleptic rigidity, 492 
Cataract with diabetes mellitus, 514 
Catarrh, atrophic gastric, anacidity in, 325 
bronchial, diminished vesicular breathing 
in, 124 
dry rales in, 128 
chronic gastric, superacidity in, 325 

relation to nervous disease, 525 
intestinal, diarrhea in, 336 
pain on pressure in, 277 
nasal, as a symptom, 66 
of apices of lungs, dry rales in, 129 
of bronchial tubes, dyspnea in, 85 
of intestine, bacterium coli commune in, 
352 
bilious stools in, 337 
distention of abdomen in, 278 
epithelial cells in stools of, 348 
fat in feces in, 348 
intestinal infarction in, 338 
mucous stools in, 337 
reaction of stools in, 336 
watery stools in, 338 
of larynx, appearance of larynx in, 538 
of stomach, condition of stomach-contents 
in, 311 
detection by test-meal, 314 
hypacidity in, 324 
hyperacidity in, 325 
hypersecretion of, 325 
microscopic appearance of stomach-con- 
tents in, 316 
of trachea, cylindrical epithelial cells in 
sputum of, 151 



INDEX. 



563 



I 



Catarrh, ulceration of larynx in, 539 
Catheter, use of, a cause of cystitis, 528 
Cathodal closure, 467 

opening, 467 
Cat's purring, 196 

Caudate nucleus, blood-supply of, 422 
Causes of disease, 21 
Celii, method of staining malarial parasites in 

blood, 248 
Celsius's thermometer, 50 
Centers, motor, 416 

of special senses, 420 

reflex, 419 
Centigrade thermometer, 50 
Central fiber of Curschmann's spiral, 154 

motor tract, lesions of, effect of, 424 

nervous system, injuries of, glycosuria in, 
402 

paralysis, arrest of growth of bones after, 
530 

scotoma, when occurs, 521 

vomiting, 326 
Centrifuge for examining urine, 374 
Centripetal tracts, 420 
Cephalalgia, 446 
Cercomonas in sputum, 158 
Cerebellar ataxia, 488 
Cerebellum, disease of, vomiting in, 527 
Cerebral abscesses generally multiple, 532 

affections, ataxia in, 488 

artery, middle, importance of, 422 

" blowing,'" 221 

congestion with uremia, 399 

nerves, course of, 418 

paralyses, increase of tendon reflexes in, 461 

paralysis of children, hemiathetosis in, 492 

peduncle, effect of lesions of, 427 

tumors, Cheyne-Stokes' respiration in, 82 
Cerebrospinal fluid, examination of, 435 

meningitis. See Meningitis. 
Cerebrum, diseases of, atrophy from, 456 
Cervical spinal cord, injury of, fever in, 525 

veins, diastolic collapse of, 229 

vertebrae, caries of, a cause of defective 
motility of head, 495 
Cestodes, 341 
Chain-cocci in urine, 383 

Charcot on pressure on hysterogenous zone 
arresting an hysterical spasm, 529 

stigmates hysteriques, 533 
Charcot's crystals in feces, 349 
in leukemic blood, 244 

diagram of aphasia, 510 
Charcot-Leyden crystals, 149 

in sputum, 156 
Chest, alterations of form of, by deformity of 
skeleton, 78 

asymmetry of, 73 

delineation of cross-section of, 140 

pathological forms of, 75 

pigeon, 78 

rachitic, 78 

-wall, thickenings of, vocal fremitus in, 134 
Cheyne-Stokes' respiration, 81 
cause of, 83 
dyspnea in, 84 
in brain disease, 82 



Cheyne-Stokes' respiration in uremia, 399 
Chiasm, pressure on, primary atrophy of optic 

nerve in, 547 
Chill described, 56 
Chloral-poisoning, glycosuria in, 401 
Chlorate-of-potash poisoning, color of blood 
in, 233 
icterus from, 42 
Chlorid-of-iron reaction for diacetic acid, 407 

of urine, 373 
Chlorid of sodium in urine, 365, 392 
Chloroform-poisoning, icterus from, 42 

odor from mouth in, 253 
Chlorosis, ascending venous pulse in, 229 
color of blood in, 233 

of urine in, 369 
diminution of percentage of hemoglobin in, 

238 
Egyptian. See Egyptian Chlorosis. 
frequent pulse in, 207 
heart-murmurs in, 197 
sounds over arteries in, 222 
strengthening of heart-sounds in, 187 
syncope in, 438 
venous humming in, 230 
Choked disk, 513 

as a sympton, 533 

disturbance of vision by, 547 

easily confounded with neuroretinitis, 

547 
significance of, 546 
Cholemia from long-standing jaundice, 4I 
Cholera, Asiatic, anuria in, 367 
bacillus of, 350 
habitat of, 350 

mode of preparing cultures, 350 
diarrhea in, 334 
indicanuria in, 369 
mucous vomit in, 328 
rice-water stools in, 338 
watery stools in, 338 
bacillus, 553 

in feces, 350 
increase in amount of feces in, 335 
reaction, value of, 554 
stools, odor of, 336 
sweat in, 34 
Cholesterin-crystals in sputum, 156 
Chordal paralysis, unilateral ageusis in, 524 
Chorea, disturbance of conception of motion 
in, 446 
embolus of central artery of retina in, 548 
minor, 441 
Choroid, tubercle of, 547 

Choroidal tuberculosis in acute miliary tuber- 
culosis, 514 
Choroiditis syphilitica, 547 
Chrysophanic acid, discoloration of urine by, 

371 
Chylous ascites, 286 
Chyluria, 371 

caused by filaria sanguinis hominis, 382 
fibrin in urine of, 398 
lipemia in, 245 
lipuria in, 406 
Chyme, hydrochloric acid in, determination 
of, 320 



564 



INDEX. 



Ciliated epithelium of trachea, transfer of 

mucus by, 143 
Circle of Willis, 422 
Circulation, disturbance of, casts in urine in, 

380 
Circulatory apparatus, examination of, 166- 

relation of disturbances of, to nervous 

disease, 526 
Circumpolarization for determining sugar in 

urine, 406 
Cirrhosis of liver, alcoholic, urobilinuria in, 

369 
ascites in, 282 
bloody vomit in, 329 
color of urine in, 369 
disappearance of dulness in, 296 
enlargement of spleen in, 298 
increased consistence in, 292 
surface of liver in, 291 
tenderness in, 290 
Citron on proportion of albumin in pleural 
exudations, 139 
on Reuss's formula for estimating albumin, 
140 
Clavus hystericus, 447 
Claw-hand, 499 
Clear percussion-sound, 94 
Clinical law of contraction, 467 
Clod-voice, 502 
Clonic spasms, 488 

when occur, 490 
Closed tympanic sound, 98 
Cloudiness of urine in disease, 371 
Coalescence of ear drum with wall of tym- 
panum, 546 
Coal -soot in sputum, 147 
Coal-tar preparations, color of urine after 

taking, 371 
Coating of tongue, 255 
Cocain, effect of, on pupil, 517 
Cod-liver oil, lipuria after taking, 407 
Coffee-grounds stools, 339 

vomit, 329 
Coffin-lid crystals in urine, 389 
Cohnheim on cause of edema, 48 
on polyuria in diabetes, 367 
reference to, 47 
Cohnheim's hypothesis of dropsy in kidney- 
disease, 399 
Cold bath. See Bath. 
Colic, bradycardia in, 204 
from gall-stones, 339 
renal, 391 
Collapse, cold sweat of, 34 
described, 57 

sudden fall of temperature in, 59 
weakening of apex-beat in, 174 
Colon bacilli, 551 

distention of, for diagnostic purposes, 280 
determination of boundary of, by inflation, 

280 
position of, illustrated, 269 
relation of, to spleen, 299 
tumors of, confounded with those of spleen 
and kidney, 279 
Color-sense, testing of, 522 



Columns of Clarke, 420 

of Tiirck, 417 
Coma, breathing in, 81 
carcinomatous, 437 
definition of, 437 

diabetic, apple-odor of urine in, 373 
casts in urine of, 380 
caused by oxybutyric-acid poisoning, 

407, 408 
diaceturia with, 407 
difficulties of diagnosis in, 437 
in diabetes mellitus, 528 
post- epileptic, 490 
uremic, 399 
Combined system- disease, 532 
Comma bacilli in vomit of Asiatic cholera. 

Compensation of valvular insufficiency, 169 
Compensatory hypertrophy of heart, 169 
Compression of spinal cord, herpes zoster in, 

529 
Compulsory positions, 30 
Concealment of disease, 19 
Concentrated urine, appearance of, 363 
Conception of localization, testing of, 444 

of space, testing of, 445 
Concretions in urine, 391 
Concussion of brain, glycosuria from, 402 
Conductive resistance, determination of, 474 
Conductivity of bones for sound, testing of, 

522 
Confluent sputa, 145 
Congestion of liver, urobilinuria in, 369 
Congo-red test for hydrochloric acid in stom- 
ach, 316 
Conjugate deviation, 514 

diagnostic signification of, 516 
Conjunctiva, color of, 35 (note) 

nerve supply of, 448 
Consciousness, disturbances of, 437 
Consolidation of lungs a cause of cyanosis, 

39 
Consonant rale, 130 
Constipation, t^t^^) 

alternating with diarrhea, 334 
and severe obstruction to be sharply dis- 
tinguished, 334 
habitual, in nervous disease, 527 
Constrained positions and motions, 491 
Constricted liver from tight lacing, 290 
Constriction, feeling of, about thorax, 446 
Consumption, dry cough in, 143 
Contents of stomach, examination of, 303 
Continued fever in the course of febrile dis- 
eases, 61 
range of temperature in, 56 
Continuous secretion of gastric juice, 311 
Contracted kidney, retinitis albuminurica, 547 
Contraction, cathodal closure, 467 
opening, 467 
clinical law of, 467 
electrical, normal laws of, 468 
Contractions, fibrillary, 489 
idiomuscular, 485 
paradoxical, 486 

produced by electric stimulation of nerves, 
468 



INDEX. 



565 



Contractures from paralyses, 457 

of muscles in paralysis, 457 
Conus arteriosus, sound caused by filling of, 
184 

terminalis, location of, 434 
Convalescence indicated by weight of body, 

. 31 . 

perspiration m commencement 01, 34 

pulse in, 202 

temporary imbecility in, 438 
Convergent strabismus, 514 
Convolutions of brain, illustrated, 415 
Convulsions, epileptic, described, 490 
glycosuria after, 402 
opisthotonos in, 434 

hysterical, 491 

opisthotonos in, 434 

infantile, from eruption of teeth, 254 

with uremia, 399 
Cooing in intestines, value of, 281 
Co-ordinated spasms, 491 
Co-ordination and ataxia, 486 

how acquired, 486 

of speech, test for, 418 

temporary loss of, 488 
Copaiva, odor of urine after taking, 373 
Copper-poisoning, teeth and gums in, 254 
Coracobrachialis, function of, 498 
Cord, spinal, compression of, by kyphosis, 

434 
Corona radiata, 417 

effect of lesion of, 425 
Corpora quadrigemina, ataxia from lesions of, 

468 
Corpus striatum, effect of lesion of, 427 
Cortex cerebri, lesion of, effect of, 424 

moior centers of, 419 
Cortical center, lesions of, effect of, 425 
Corvisart, revived percussion, 92 
Costal breathing, 74 
Cough, 142 

as a sign of disease, 142 

character of, in disease of larynx, 67 

dry, 143 

frequency of, 142 

in whooping-cough, 143 

moist, 143 

nervous, 525 

reflex, 142 

suppression of, 142 

time of day when most apt to occur, 142 

tone of, 143 

vomiting from, 143 

with tough expectoration, 143 
Coupland on value of record-keeping, 25 
Cracked-pot sound, III, 116 

moist, 116 
Cranial nerves, location of nuclei of, 424 

points of exit from skull, 424 
Cranium, diminution of size of, 431 

enlargement of, 430 

examination of, 430 

form of, 431 

injuries and concussions of, disturbance of 
consciousness in, 437 

sensibility of, to pressure, 433 

size of, 430 



Creasote, color of urine after taking, 371 
Cremaster reflex, 458 
Crepitant rales, 131 
Crepitation, 131 

atelectatic, 131 

indux and redux, 131 

non-uniform, 132 
Cretinism, 438 

Crico-arytaenoidei postici, paralysis of, 542 
Crico-thyreoidei, paralysis of, 543 
Crises, gastric, 527 

laryngeal, 525 
Crisis defined, 56, 61 

protracted, 61 
Critical perturbation, 61 
Crossed paralysis of eye, significance of, 517 

reaction, examination of, 518 
Croup a cause of cyanosis, 38 

casts of trachea and larynx in, 149 

dyspnea in, 84, 85 

inspiratory drawing-in of, 87 

laryngitis in, 68 

tone of cough in, 143 
Crural artery, auscultation of, 221 
Crus cerebri, tumor of, effect of, 426 
Crutch-paralysis, 451 
Crystals in sputum, 149, 155 

in stools, 349 

of fatty acid in sputum, 156 

of hematoidin in sputum, 155 
Cubebs, odor of urine after taking, 373 
Curare-poisoning, glycosuria in, 401 
Current-changer, 466 

-strength, irritating, 463 
measurement of, 464, 465 
total, 463 
Currents, electric, measuring of, 464, 465 
Curschmann's spirals, 154 

origin of, 155 
Curvature of spine, lateral, recognition of, 

434 
Curve at the base, 212 
Cutaneous reflexes, 457 

sensibility, 439 

veins, enlargement of, 224 
Cyanosis, 38 

causes of, 38 

color of tongue in, 254 

from general venous engorgement, 224 

from severe coughing, 143 

in general neuroses, 526 

in tetanus and epilepsy, 496 

of new-born, 38 
Cyclic albuminuria, 394, 396 
Cylindroids, diagnosis of, from urinary casts, 

375 

in urine, 375 
Cyrtometer, 140 
Cystic hemorrhage, appearance of blood in 

urine from, 376 
Cysticerci in brain and eye, 527 
Cystin, concretions of, in urine, 391 

in urine, 390 
Cystitis, alkaline fermentation of urine in, 383 

cylindroids in urine of, 375 

from cystin in urine, 390 

from ptomains in urine, 390 



566 



INDEX. 



Cystitis from use of catheter, 528 
hematuria in, 376 
in nervous affections, 528 
increased mucus in urine of, 375 
micro-organisms in urine of, 383 
odor of urine in, 373 
pus in urine of, 377 
reaction of urine in, ;^']^ 
signs of, 361 

sulphuretted hydrogen in urine in, 374 
tenesmus of bladder in, 361 
turbid urine in, 371 
white blood-corpuscles and pus in urine of, 

377 
Cystopyelitis, thickening or tenderness of 

ureters in, 359 
bacterium coli commune in, 383 
Cystopyelonephritis, bacterium coli commune 

in, 383 

Dahmen's method of demonstrating tubercle 

bacilli in sputum, 161 
Damoiseau's curve, 1 11 
Dax on speech-disturbance, 506 
Deadened resonance, 109 

sound, relatively, where it occurs, lOO 
when heard, 99 
Deadness applied to sound, 94 

absolute and relative, 95, 96 

percussion, 94 
Deafness, testing for, 522, 523 
Death-agony, breathing in, 81 
Decubitus, 530 

acutus, 530 

disturbance of nutrition with, 525 

malignus, 530 

ordinary, 530 
Deep breathing, employment of, in examining 
abdomen, 290 

percussion sound, 95 

sensibility, testing of, 444 
Defervescence of fever, 59 
Deforming arthritis in hemiplegia and tabes, 

531 

in syringomyelia, 531 
Degeneration of cord, character of, as deter- 
mined by location of lesion, 425 
of nerves and muscles, 480 
reaction of, 478. See Reaction of degener- 
ation. 
Deglutition-pneumonia from paralysis of 

tensor of vocal cords, 543 
Dehio on origin of puerile breathing, 122 
on proportion of hemoglobin to number of 
red corpuscles in phthisical and car- 
cinomatous cachexia, 239 
table of variations of examinations of 
blood with Fleischl hemometer, 234 
Delayed sensibility, 443 
Delirium, 438 

in gross hysteria, 491 
muttering, 438 
tremens described, 438 
with uremia, 399 
Deltoid muscle, electrical stimulation of, 471 

paralysis of, effect of, 497 
Dementia, hand-writing in, 513 



Dementia paralytica, primary atrophy of optic 
nerve in, 547 
senilis, 438 
Dentition, disturbances due to, 254 

epileptiform attacks during, 490 
Dermatograph, value of, 103 
Desaga's spectroscope, 235 
Detritus in stools, 348 
Deviation, conjugate, 491, 514 
of the eye, 514, 515 
primary, 515 
secondary, 515 
Dextrin, absorption of, by stomach, 307 
Diabetes, absence of free hydrochloric acid 
from stomach in, 324 
acetone in urine of, 409 

odor from mouth in, 253 
casts in urine in, 380 
coma from, 437 
decipiens, 367 
diaceturia with, 407 
diminished alkalescence of bloocl in, sJC 

salivation in, 256 
dyspnea in, 525 
gangrene in, 526 
increase of urea in, 392 
insipidus in nervous diseases, 528 

inosite in urine of, 406 
lipemia in, 245 
local asphyxia in, 526 
mal perforant in, 530 
mellitus, apple-odor of urine in, 373 
caries of teeth in, 253 
cataract in, 514 
color of urine in, 369 
grape-sugar in urine, 401 
high specific gravity of urine in, 372 
levulose in urine of, 406 
nervous diseases in, 528 
oxalate of lime crystals in urine of, 388 
neuralgia in, 447 
neuroretinitis in, 547 
oxalate of lime in sputum of, 157 
oxybutyric acid in, 407 
perforating disease of foot in, 530 
polyuria in, 367 
symmetrical gangrene in, 526 
thirst in, 23 
Diabetic coma, acetone odor from mouth in, 

253 . 

alteration of vesicular breathing in, 124 
dyspnea in, 525 
diaceturia with, 407 
Diacetic acid in urine, 407 
Diaceturia, 407 
Diagnosis defined, 17 
etiological, 17 
individual, 18 
Diagnostic value of symptoms in nervous 

disease, 531 
Diaphanoscopy of stomach, 276 
Diaphragm, action of, in stenosis of upper 
air-passages, 87 
depression of, from emphysema, 173 
elevation of, causes displacement of heart, 

^n 

fixation of, in hysteria, 526 



INDEX. 



567 



Diaphragm, paralysis of, 80, 496 
inspiratory dyspnea in, 88 
upward displacement of liver from, 289 
position of, 71 
spasms of, effects of, 496 
increased respiration in, 85 
Diaphragmatic breathing, 74 
friction sounds, 200 
phenomenon, 74 
Diarrhea, 2)Z'i 
anuria in, 367 

brick-dust sediment in urine of, 387 
diminution of sweat in, 34 
diminished salivation in, 256 
from dentition, 254 
increase in amount of stools in, 335 
infantile, odor of stools in, 336 
low specific gravity of urine in, 372 
Diastole, movement of blood in, 168 
Diastolic collapse of cervical veins, 229 
murmur, how distinguished from systolic, 
194 
in mitral stenosis, 193 
Diazo-reaction, 409 
Dicrotic pulse, 213 
Diet, effect of, on disease, 21 
Differentiating electrode, 462 
Difficult breathing, 83 
Digestion, amylolytic period of, 305 

disturbed food-particles in feces in, 347 
examination of process of, 304 
intestinal, shown by stools, 333 
products of, examination of, 32 1 
Digestive apparatus, examination of, 252 

disturbances of, in relation to nervous 
diseases, 526 
Dilatation of heart a cause of valvular insuf- 
ficiency, 168 
area of dulness in, 181 
eccentric, 169 
in anemia, 197 
of stomach, reaction of urine in, 372 
vomit in, 327 
Diminished irrital)ility, significance of, 484 
Diphtheria a cause of cyanosis, 38 
acute nasal catarrh in, 67 
bacillar, differential diagnosis of, from lacu- 
nar angina of follicular tonsillitis, 
258 
bacilli, 551 

bacillus, determination of, 260, 262 
bacteriological diagnosis of, 260-263 
differentiation of, from diphtheroid anginas, 

259 

from necrotic angina, 259 

from scarlet fever, 259 
gallop rhythm in, 191 
glycosuria in, 402 
paleness in, 36 

paralysis of tensor of vocal cords in, 543 
sometimes no contraction of pupil after, 

swelling of lymphatic glands of neck in, 

260 
tone of cough in, 143 
tonsils in, 258 
Diplococcus in urine, 361 



Diplococcus of FVankel in exudations of 

empyema, 138 
Diplopia, 514 

mode of determining, 515 

significance of, 515 
Direct irritation, 466 
Disease, course of, 22 

concealment of, 20 

exciting causes of, 22 

first appearance of, 22 

present, 22 

previous, as a cause of other disease, 22 

simulation of, 20 
Disseminated paralysis, reaction of degenera- 
tion in, 479 
" Dissociated spasms," 425, 490 
Distention of stomach, 270, 271 
Distoma haematobium in blood, 250 
in urine, 382 

hepaticum, 346 

lanceolatum, 346 

pulmonale in sputum, 158 
Disturbances of speech, 502 

of vegetative system in nervous disease, 

525 
Divergent strabismus, 514 
Diverticula of esophagus, sounding for, 267 
Dizziness, 438 
Dolichocephalus, 431 
Dorsal clonus, 460 
Double sensibility, 443 

vision, 514 

significance of, 515 
determination of, 515 
Drawing-in of abdomen, 278 

of chest, inspiratory, 87 
Drinks which cause polyuria, 367 
Dropsy, anidrosis with, 34 

causes of, 47 

edema of larynx in, 539 

of engorgement with kidney-disease, 399 

of kidney-disease, 398 

orthopnea with', 29 
Drumstick crystals in urine, 389 
Dry cough, 143 

humming, 128 

rales, 128 
Duboisin, effect of, on pupil, 517 
Duchenne, investigations on motor-points on 

body, 469 
Ductus choledochus, compression of, 302 
Duhomme's approximate determination of 

sugar in urine, 406 
Dulness, percussion, 94 

relative, 94, 95 

heart- and liver-, 108 
Dumb-bell crystals in urine, 388 
Dumbness, hysterical, 502 
Dura mater, diseases of, projections on skull 

in, 431 
Duroziez's double murmur, 222 
Dust, inhalation of, a cause of disease, 21 
Dynamic sense, testing of, 444 
Dynamometer, value of, in testing paralysis 

of hand, 500 
Dysarthria, 502 
Dysentery, color of stools in, 337 



568 



INDEX. 



Dysentery, meat-juice stools of, 338 
odor of stools of, 336 
pain at stools in, 335 

in left iliac fossa in, 278 
watery stools in, 338 
Dyspepsia, bacteria of mouth increased in, 
.257 
chronic, subacidity combined with retarded 

evacuation in, 326 
coating of tongue in, 255 
due to diseased teeth, 253 
foul odor of breath in, 252 
gastric headache with, 447 
headache with, 447 
intestinal, yeast fungi in feces in, 349 
nervous, 527 

hyperacidity in, 325 

normal digestion in, 324 

vomiting in, 327 

watery vomit in, 328 
odor from the mouth in, 252 
stools in, 337 
Dyspnea, 29, 83 

alteration of vesicular breathing in, 124 
as a factor in nervous disease, 525 
color of blood in, 233 
expiratory, 88 

from emphysema of skin, 50 
from uremia, 399 
in emphysema of lung, 75 
in heart-diseases, 86 
in paralysis of diaphragm, 446 
inspiratory, 88 
lung-, 85 
mixed, 89 
mydriasis with, 517 
objective, %t, 
of fever, 84 
perspiration in, t^t^ 
physiological, ?>'}, 
subjective, 83 
Dystrophia, muscular, 455 

musculorum, hypertrophy of gastrocnemius 

in, 456 
pseudohypertrophy in, 456 

Ear, affections of, in diseases of nervous 
system, 523 
importance of determining disease of, 523 
otoscopic examination of, 545 
subjective sensibility of hearing in disease 

of, 523 ... 

suppuration of, as a cause of memngitis, 

433 
Ear-drum, bulging outward of, 546 

coalescence of, with wall of tympanum, 546 
inspection of, 545 
pathological alterations of, 545 
retraction of, 545 
ruptures and perforations of, 546 
Ebstein on lipuria in pyonephrosis, 406 
Ebstein's method of determining resistance 

of heart by percussion, 180 
Eccentric dilatation of heart, 169 
Ecchymoses, 45 

Echinococcus bladders in liver, fluctuation of, 
292 



SI 



Echinococcus in sputum, 
in urine, 382 
in vomit, odor of, 332 
membranous rags of, in vomit, 331 
of kidney, palpation of, 358 
of omentum, 303 
of spleen, tumors on surface of organ in, 

298 
surface of liver in, 292 
Eclampsia gravidarum, 490 
Eclamptic attacks in children, 490 

convulsions, cutaneous hemorrhage in, 46 
Ectasia venarum, 46 
Edema, 46 
cause of, 48 
collateral, 48 
diseases which cause, 47 
distinguished from emphysema of skin, 49 
from general venous engorgement, 224 
from kidney-disease, 399 
from nephritis, 48 
in paralysis, 526 
inflammatory, 48 
malignant, bacilli of, 550 
of chest- wall, deadening of chest-resonance 
in, 112 

diminished vesicular breathing in, 124 
of larynx, appearance of, 538 
of lungs, crepitant r§,Ies in, 13I 

dyspnea in, 85 

hemorrhage in, 146 

non-uniform crepitation in, 132 

serous sputum in, 145 

tympanitic sound in, 98, 1 13 

with pneumonia, prune-juice sputum in, 

145 
of skin and subcutaneous cellular tissue, 46 
weakened apex-beat in, 174 
Effusion in abdominal cavity, 282 

into pleural cavity, change of boundaries 

of deadness in, 112 
of blood, reaction of urine in, 372 
Egophony, 135 

Egyptian chlorosis, 345. See Anchylosto- 
fniasis. 
paleness in, 36 
Ehrlich, gigantoblasts, 240 
Ehrlich's diazo-reaction, 409 

method of staining tubercle bacilli, 160 
Eichhorst on Ebstein's percussion for deter- 
mining resistance of heart, 180 
on odor of echinococcus in vomit, 332 
on paint-like odor of sputum, 147 
on the sound of crepitant riles, 131 
Einhorn's apparatus for illuminating stomach, 
276 
fermentation saccharometer, 404 
Elastic fibers, how to obtain for examination, 

153 
in sputum, 152 
Electric sensibility to pain, 441 

stimulation of nerves, 467 
Electrical condition, diagnostic value of, 484 
examination in detail, 469 

of nerves and muscles, 462 
reaction, mixed, 483 
Electrode, differentiating, 462 



INDEX. 



569 



Electrode, Erb's fine, 463 
use of, 473 

indifferent, 4O7 
Emaciation, how detected, 31, 32 

significance of, 31 
Emboli, effect of, on pulse, 211 

of central retinal artery a precursor of cere- 
bral embolism, 547 
Embolism, local, low temperature in, 65 
Embolus of central artery of retina, 548 

of retinal artery in endocarditis aortae, 514 
Embryocardia, 190 
Emesis, induction of, when contraindicated, 

304 
Emphysema a cause of hypertrophy of right 

ventricle, 120 
anomalies of breathing in, 80 
anuria in, 368 
aspiration, 49 

diminution of expiratory pressure in, 141 
distinguished from edema, 49 
downward displacement of liver in, 289 
dry rales in, 129 
dyspnea in, 75 
enlargement of liver in, 289 
gallop rhythm in, 191 
liver-dulness in, 295 
of lung, abnormally loud percussion-sound 

in, 116 
a cause of cyanosis, 39 
a cause of displacement of apex-beat, 

173 

band-box note in, 116 

diminished vesicular breathing in, 124 

diminution of heart-dulness in, 181 
of spleen-dulness in, 301 

dyspnea in, 85 

expiratory dyspnea in, %?> 

extension of boundaries of lungs in, 117 

from bronchial asthma, 89 

non-tympanitic sound in, 99 

rales with, 128 

systolic pulsation in epigastrium, 177 

thorax in, 75 

vein-nets on chest and back in, 225 

venous engorgement in, 224 

vicarious, one-sided downward move- 
ment of lung-boundary in, 117 
of mediastinum, diminished heart-dulness 

in, 182 
of skin, 49 

diagnostic importance of, 50 

weakened apex-beat in, 174 
peptonuria with, 398 
prolonged expiration-sound in, 1 24 
relative liver-dulness in, 296 
vicarious, 76 
Emphysematous thorax, 75 
Emprosthotonos, how produced, 496 
Empyema, amount of expectoration in, 144 
bacteria in exudations of, 138 
expansion of chest in, 77 
Frankel's pneumococcus in pus of, 1 63 
hematoidin-crystals in pus of, 156 

in sputum in, 147 
necessitatis, 90 
pulsans, 90, 176 



Empyema, pulsatile, 90 

pulsation in heart-region in, 176 

purulent sputum in, 145 

staphylococcus pyogenes in, 548 

tyrosin in sputum of, 157 
Encapsulated pleurisy, 1 1 1 
Encephalitis, arrest of growth of bones after, 
. 530 

chronic motions in, 492 

epileptiform attacks in beginning of, 490 

neuroretmitis in, 547 
Endocardial murmurs distinguished from peri- 
cardial, 199 
loudness of, 195 

whizzing, 196 
Endocarditis a cause of insufficiency, 168 

a cause of stenosis of a valve, 168 

acute, hematuria in, 375 

aortae, embolus of retinal artery with, 514 

embolus of central artery of retina in, 548 

hematuria with, 375 

mitralis, embolus of retinal artery in, 514 

pus-cocci in urine in, 385 

streptococcus pyogenes in, 549 

ulcerative, staphylococcus pyogenes in, 548 
Engorgement, abnormal redness of mucous 
membrane of larynx in, 538 

of kidneys, albuminuria in, 394 
hematuria from, 375 

of liver, surface of liver in, 291 

of spleen, tenderness in, 298 
Enlarged glands, pressure by, upon recurrent 

nerves, 543 
Enrichment defined, 553 
Enteritis, color of stools in, 337 

poor resorption of fats in, 335 
Enteroliths in stools, 340 
Enteroptosis, floating kidney a symptom of, 

358 
Enuresis from irritation of penis, 529 

nocturna, 528 
Eosinophile cells, 242 
Epigastric angle, 73 
Epigastrium defined, 268 

illustrated, 269 

pulsation of, 177 
Epilepsy, acetonuria after, 409 

albuminuria after, 394 

coma from, 437 

convulsions or spasms of, 490 

cyanosis in, 39 

dyspnea in, 95 

glycosuria after, 402 

hemorrhage into subcutaneous tissue in, 

530 
involuntary discharge of urine in, 528 
Jackson's, 490 
partial, 490 
polyuria in, 367 

punctiform ecchyraoses after, 529 
spermatozoa in urine in, 379 
spermatorrhea in, 414 
Epileptic attacks, fever in, 525 
tonic spasms in, 490 
wounds of tongue from biting in, 254 
Epileptiform attacks in children, 490 
Epistaxis, 66 



570 



INDEX. 



Epithelial casts in urine, 382 

cells in saliva, 256 
in sputum, 151 
in stomach-contents, 316 
Epithelium in sputum, 151 

in stools, 348 

in urine, 378 

in vomit, 331 
Equinia, acute nasal catarrh in, 68 

bacilli in urine, 385 
Erb, muscular dystrophia, 455 

myotonic reaction, 483 

on partial reaction of degeneration, 483 
Erb's electrode for testing paradocutaneous 
sensibility, 442 

fine electrode, 463 
use of, 473 

point, 471 
Erector trunci, paralysis of, 495 
Ergotism, symmetrical gangrene in, 526 
Ernst on nature of hyaline casts, 381 
Eructation, 327 
Erysipelas cocci in urine, 385 

continual fever in, 59 

enlargement of spleen in, 298 

leukocytosis in, 242 

staphylococcus pyogenes in, 548 

vomiting in, 326 
Erythema exudativum multiforme, 44 
Erythrodextrin from digestion of starch, 304 

test for, 321, 322 
Esbach's albuminometer, 397 
Eserin, effect of, on pupil, 517 
Esophagoscopy, 268 
Esophagus, anatomy of, 263 

auscultation of, 268 

dilatation of, 267 

diverticula of, detection by sounding, 267 

examination of, 263 

of neighborhoofl of, 267 
with sound, 264 

obstruction of, 267 

palpation of, 264 

percussion of, 267 

sounding of, difficulties and dangers of, 265 

stenosis of, characteristic distress with, 263 

stricture of, location of, by sounding, 266 
Esthesiometer, use of, 440 
Ether-poisoning, jaundice from, 42 
Etiological diagnosis, 17 

Ewald's salol method of determining rapidity 
of evacuation of stomach-contents 
into duodenum, 322 

test-meal, 311 
Examination, chemical, of aspirated fluid, 139 

electrical, 462-485 

of arteries, 201 

of Vjlood, 231 

of digestive apparatus, 252-354 

of esophagus, 263 

of feces, 332 

of heart, 166-201 

of intestines, 277 

of kidneys, 355 

of lips, 253 

ofliver, 286-296 

of mouth, 252 



Examination of nervous system, 415 

of omentum, 302 

of pancreas, 302 

of patient, 24 

form for recording, 26, 27 
general, 28 

of peritoneum, 281 

of secretions of male genito-urinary appa- 
ratus, 411 

of stomach, 268 

of stomach-contents, 303 

of spleen, 296 

of teeth, 253 

of tongue, 254 

of urinary apparatus, 355 

of urine, 360 

of veins, 223 
Examining electrode, application of, 467 
Exanthemata from poisons and use of medi- 
cines, 45 
Excitability, mechanical, of muscles and 
nerves, 485 

quantitative, of nerves and muscles, 476 
Excitement, effect of, on amount of urine, 636 

headache after, 446 

strengthening of heart-sounds in, 187 

syncope in, 438 
Exophthalmos paralyticus, 515 
Expectoration, 143 

examination of, 144 

general characteristics of, 144 

green, 147 

hemorrhage with, 146 

odor of, 147 

varieties of, 144 
Expiration, auxiliary muscles of, 87 
Expiratory bulging, 88 

dyspnea, 88 
Exploratory puncture of abdomen, 285 
of heart, 200 
of pleura, 136 
Explosive speech, 502 
Extensors of hand, paralysis of, 498, 499 
Extirpation of pancreas a cause of diminished 

fat-digestion, 348 
Extra-pericardial friction-sounds, 200 
Extravasations, chylous and chyliform, from 

the pleural cavity, 137 
Extremity, measurement of volume of, 453 
Exudation, diagnosis from transudation by 

exploratory puncture, 137 
Exudations, examination of, for bacteria, 1 38 

in cavum tympani, 546 

metapneumonic, 138 

microscopic appearances of, 137 

plegaphonia over, 135 
Eye, affections of, in diseases of nervous sys- 
tem, 513 

cysticerci in, 527 

movements of, 514 • 

paralysis of muscles of, 513-515 
significance of, 516 
Eyelids, dropsy of, from kidney-disease, 398 

Face, motor-center for lower part of, 417 

muscles of, 492, 493 
Facial nerve, effect of paralysis of, 493 



INDEX. 



571 



Facial nerve, lesion of, from caries of petrous 
bone, 436 
motor tracts of, illustrated, 426 
- paralysis, 493 
cerebral, 493 

diminished secretion in, 527 
hearing in, 523 
testing of taste in, 524 
phenomenon, 485 
reflexes, 460 

tract, paralysis of, bone-reflex in, 461 
Facialis, course of, 418 

Faradic apparatus for electrical examination, 
462 
current causes tetanic contraction, 467 
examination of nerve, method of, 473 
Faradocutaneous sensibility, 441 
Fat-drops in urine, 378 

development of, in different persons, 30 
in conjunctiva not to be confounded vi'ith 

jaundice, 40 
in stools, 348 
in urine in health, 366 

make it turbid, 371 
variations in amount of, 30 
Fatigue as a factor in causation of disease, 21 
Fatty-acid crystals in sputum, 156 

in sputum of gangrene of lungs, 164 
in stools, 348 
in urine, 407 
degeneration of heart, Cheyne-Stokes res- 
piration in, 82 
of kidney, renal epithelia in urine of, 

379 
heart, paleness in, y] 

retardation of pulse in, 204 
stools, 338 
Favus fungus in vomit, 332 
Febrile diseases, ascending venous pulse in, 
229 
diminished salivation in, 256 
heart-murmurs in, 197 
retardation of pulse in, 204 
with heart disease, frequent pulse in, 205 
hyperemia of mucous membranes, redness 
of mucous membrane of larvnx in, 

Febris hepatica, herpes with, 45 

Fecal accumulation in stenosis of intestine, 

334 

odor of stools, 336 

vomiting, 330 
Feces, amount of, 335 

balls of, in intestine, palpation of, 279 . 

chemical examination of, 353 

examination of, 332 

microscopic examination of, 347 

mixed with blood, significance of, 339 

physical and chemical properties of, 336 
Feculent exudation in pleural exudation, 139 

odor of urine, 373 
Feeling of constriction, 446 
Fehleisen on erysipelas cocci in urine, 385 
Fehling's solution in testing for sugar in urine, 

404 
Female sexual organs, headache with disease 
of, 447 



Femoral vein, compression or thrombosis of, 
engorgement of cutaneous veins of 
leg from, 224 
Ferment in sputum, 164 
Fermentation of stomach-contents, 309 

of urine, alkaline, a sign of cystitis, 383 
caused by micro-organisms, 383 
reaction of urine in, 373 
ammoniacal, odor of urine in, 373 

test for sugar in urine, 403 
Ferments, function of, in digestion, 306, 307 
Fever, 50, 54 

acetonuria in, 409 

albuminuria in, 394 

anuria in, 367 

as a symptom in nervous diseases, 531 

brick-dust sediment in urine in, 387 

casts in, 380 

chill of, paleness in, 36 

chlorid of sodium in urine diminished in, 
392 

coating of tongue in, 255 

color of urine in, 369 

continued. See Continued fever. 

daily difference of, 56 

diaceturia in, 407 

diminished alkalescence of blood in, 25O 

dryness of tongue and throat in, 254 

exacerbation of, 56 

frequent pulse in, 204 

hectic. See Hectic fever. 

hyaline casts in urine of, 380 

hyperpyretic, 55 

importance of observing pulse in, 205 

increased mucus in urine of, 375 

increase of urea in, 392 

increased frequency of respiration in, 84 

in nervous diseases, 525 

intermittent. See Intermittent fever. 

irregular, 64 

lips in, 253 

paroxysm, 63 

perspiration in, 33 

pulse in, 204 

recurrent. See Recurrent fever. 

red skin in, 37 

remission of, 56 

remittent. See Reiniitent fever. 

sounds over arteries in, 222 

symptom-complex of, 54 

three types of, 56 

thrush in, 255 

typical courses of, 59 

typus inversus of, 56 

uric acid increased in, 392 

urobilinuria in, 369 

variations of temperature in, 56, 57 

with albuminuria, 399 
Fibrillary contractions, 489 
Fibrin in cerebrospinal fluid, 435 

in urine, 398 
Fibrinous tubes in sputum, 148 
Fibroma of larynx, 541 
Field of vision, concentric narrowing of, 521 

testing of, 520 
Filaria sanguinis hominis, effects upon urine 
and urinary passages, 382 



572 



INDEX. 



Filaria sanguinis hominis in blood, 250 

Filehne on ferment in sputum, 164 

Filiform pulse, 209 

Finger-percussion, 93 

Fingers, paralysis of muscles of, 498 

Fischer, polyesthesia, 443 

Fischl on origin of epithelium in sputum, 

151 

Fissure of anus, pain at stools with, 335 

of Rolando, location of, 432 

of Sylvius, location of, 432 
Fleiner's modification of Mietz's test for free 
hydrochloric acid, 320 

test-meal, 312 
Fleischl's hemometer, 234 
Flexibilitas cerea, 492 
Flimmering, 522 
Floating kidney, 358 
Fluctuation a sign of fluid, 283 
Fliigge on bacilli of malignant edema, 550 
Fluid in pericardium, effect on heart-dulness, 
181 

in peritoneal cavity, 283 

palpation and percussion of, 283, 284 
Foetor ex ore, 252 
Folic musculaire, 492 
Food digested in feces, 347 

effects of, upon color of stools, 336, 337 

undigested, in stools, 336, 337, 347 

-value of nourishment, determination of, 

353 
Foot-clonus, 460 

paralysis of muscles of, 501 

perforating disease of, 530 

-phenomenon, 460 
Forearm, paralysis of muscles of, 498 
Fossa infraspinata, 69 

subspinata, 69 

supraclavicularis, 68 
Fran eke' s scarificator, 232 
Frankel's pneumococcus in sputum, 162 

staining of, 163 
Fredericq-Thompson on red border on gums 

in tuberculosis, 254 
Fremissement cataire, 196 
Fremitus, laryngeal, 67 

vocal, palpation of, 133 
Frerichs on artificial distention of stomach, 
271 

on cause of icterus neonatorum, 42 

" square position " of liver, 295 
Frick on cause of green sputum, 147 
Friction-sounds, extra-pericardial, 200 

palpable, 132 

pericardial, 198 

pleuritic, 132, 200 
Friedlander's pneumococcus in sputum, 162 

staining of, 163 
Friedreich on " change of respiratory sound," 

.99 

on diastolic collapse of cervical veins, 229 

on expiratory valvular sound in crural vein, 
230 

on starch -corpuscles in sputum of hemor- 
rhage from lungs, 155 

on venous sound in tricuspid insufficiency, 
230 



Friedreich's respiratory change of sound, 115 
Fruity odor of urine, 373 
Fuliginous deposit on lips, 253 
Fulness of veins, increased, 223 
Fundus oculi, changes in, in nervous diseases, 
546 
changes in, in other than nervous 
diseases, 547 

of stomach, position of, 269 
Fungi in sputum, 158 

in urine, 383 

pathogenic, in stools, 349 

sprouting, in stomach-contents, 316 
Fungus-spores in feces, 349 
Funnel-breast, 79 

Fiirbringer on oxalate of lime in sputum of 
diabetes, 157 

on pear-concretions in stools, 340 

on seminal fluid, 411 

on temporary relative aspermatism, 412 

urethrorrhoea ex libidine, 413 
Fiirbringer's reaction, 396 
Furuncles, staphylococcus pyogenes in, 548 

Gabett's method of staining tubercle bacilli, 

161 
Gabritschewsky's pneumatoscope, 136 
Galacturia, 371 

caused by filaria sanguinis hominis, 383 
Gall-bladder, enlargement of, liver dulness in, 
296 
location of, 287 

normal and pathological condition of, 292 
obstruction of, enlargement of liver in, 289 
palpation of, 292 
Gall-stones, appearance of, described, 340 
chemical tests for, 340 
fever in, 57 

in feces, how to find, 340 
in stools, 339 

diagnosis of, from pear-concretions, 340 
palpation of, 292 
Gallop-rhythm, 190 

Galvanic apparatus for electrical examination, 
462 
current, effect of, only at closing and open- 
ing of current, 467 
how to distinguish the poles, 416 
measurement of, 465 
quality of reaction with, 467 
examination of nerve, method of, 475 
resistance, testing of, 442 
Galvanometer, absolute, 465 

Edelmann's, 478 
Gangrene, infusoria in sputum of, 158 
" odorless," 147 

of lungs, crystals of fatty acid in sputum 
of, 156 
elastic fibers in sputum of, 152, 153 
fatty acids in sputum of, 164 
ferment in sputum of, 164 
hematoidin-crystals in sputum of, 1 56 
mucopurulent sputum in, 145 
odor of sputum in, 147 
starch-corpuscles in sputum of, 155 
spontaneous symmetrical, in nervous 
diseases, 526 



INDEX. 



573 



Gangrene, starch-corpuscles in sputum of, 155 
Gartner on bacillus enteritidis, 554 
Gases in stomach-contents, 310 
Gastric crises, 527 

crisis of tabes, hypersecretion of gastric 

juice in, 325 
juice, action of, 305 

bactericidal action of, 305 
determination of digestive power of, 321 
hypersecretion of, 311 
Gastritis, phlegmonous, vomiting of pus in, 

330 

Gastrodiaphanoscopy, 276 

Gastroduodenal catarrh a cause of jaundice, 

41 

Gastrointestinal disturbance, acetonuria in, 409 
Gastroxynsis acuta, hyperacidity in, 325 

superacidity in, 325 
Geigel on heart-sounds, 183 (note) 

on systolic pulse in vena cava, 229 
Geisler's albumin test-papers, 395 
General examination of patient, 28 
Genital apparatus, disturbances of, relation to 

nervous disturbances, 529 
Genito-urinary secretions, male, examination 

of, 411 
Gerhardt, chlorid-of-iron reaction of urine, 

373 
on displacement of low^er border of lung 

in lying down, 109 
on interrupted Wintrich's change of sound, 

"4 

on urobilin-icterus, 42 

reference to, as improver of percussion, 92 

sound over crural artery in pregnancy, 222 

(D.) on bilirubin in blood in icterus, 43 
Gerhardt's change of sound, 115 

chlorid-of-iron reaction for diacetic acid, 
407 
Gerlach on artificially-produced Curschmann's 

spirals, 155 
Gigantoblasts, 240 
Glanders-bacillus in blood, 247 
Gleet may be due to tuberculosis, 384 
Glossitis, parenchymatous, enlargement of 

tongue in, 254 
Glossy skin, nervous origin of, 529 
Glottis, paralysis of dilators of, dyspnea with, 
88 

spasm of, 541 

vibration of, in phonation, 133 
Gluteus maximus, paralysis of, effect of, 500 
Glycosuria, 401 

alimentary, 366, 402 

diagnosis between physiological and patho- 
logical, 402 

with diseases of oblongata, 528 
Gmelin's test for bile-pigments in urine, 400 
Goldschneider on perception of movement, 

445 
Goldschneider's movement measure, 445 
Gollash on eosinophilous asthma-cells, 157 
Gonococci in pus of gonorrhea, 384 
Gonococcus, 549 
Gonorrhea, hematuria from, 376 
gonococci in urine of, 384 
threads of mucus in urine of, 375 



Gonorrheal threads in urine, 375 

" Goose's throat," 220 

Gorges on physiological variation in reaction 

of urine, 364 
Gottstein on ulcers characteristic of tuberculo- 
sis of larynx, 540 
Gout, diabetes in, 447 

neuralgia in, 447 

uric acid in blood in, 250 
Gouty diathesis, uric acid increased in, 392 
Gowers's hemoglobinometer, 234 
Granular hyaline casts, 381 
Grape-sugar in urine, 401 
Graphic communication, disturbance of, 503 

representation of aphasia, 509-513 
Gray skin of silver deposit, 44 
Green sputum, 147 
Griesinger on anchylostomiasis, 345 
Growth of hair in nervous disease, 530 
Guaiac- tincture test for bile-pigment in urine, 

400 
Gummata of larynx, 540 

syphilitic, of skull, projections caused by, 

431 
on surface of liver, 292 
Gumprecht's method of percussing heart, 180 
Gums, examination of, 253 
Giiterbock on temporary relative aspermatism, 

412 
Gutbrod, recoil-theory of apex-beat, 172 

Habitation, influence on disease, 21 
Habits, influence of, on disease, 21 
Habitual constipation in nervous disease, 527 
Haematobium malariae in blood, 247 
Haeser on specific gravity of urine as a guide 
to amount of solid constituents, 372 
Hair, growth of, dependent on neurosis, 530 
Halfmoon-shaped space, diminution in size of, 
275, 276 
of, by enlargement of spleen, 302 
of Traube, 270, 275 
Hammer-pleximeter percussion, 93 
Hammond (W. A.), athetosis, 492 
Hand and fingers, characteristic positions of, 
in paralysis, 499 

distribution of nerves of, 449 

examination of, in paralysis, 499 

paralysis of muscles of, 498, 499 
Hauser on sarcina pulmonalis, 159 
Hawking, 143 

Hayem on urobilinuria in liver-affections, 369 
Hayem's counting-chamber, 239 

fluid, 239 
Head, distribution of nerves of, 448 
Headache, 446 

anemic, 447 

from uremia, 399 

habitual, 447 

toxic, 447 • 

Hearing, center for, 421 

subjective sensibility of, 523 

testing of, 522 

tract of, 420 
Heart-action, rapidity and strength of, 183 

anatomy of, 166 

auscultation of, 182 



574 



INDEX. 



Heart-beat, broad, 1 76 

rhythm of, 183 
change of form of, 1 70 
dilatation of, retardation of pulse in, 204 

tympanitic sound in, 112 
diminished work of, weakens apex-beat, 

174 
-disease, anuria in, 368 

cells in sputum in, 151 

Cheyne-Stokes' breathing in, 82 

cyclic albuminuria in, 396 

dyspnea in, 86 

edema in, 48 

pulse in, 207 

venous engorgement in, 224 
dislocation of, a cause of displacement of 

apex-beat, 172 
-dulness, absolute, 177 

diminution or loss of, 181 

displacement of, 182 

enlargement of area of, 180 

in children, 178 

relative, 108, 177, 179 
in children, 180 

size and diagnostic value of, 179 
enlargement of, a cause of displacement of 
apex-beat, 173 

expansion of chest in, 77 

simulated, 171 
examination of, 166-201 
exploratory puncture of, 200 
-failure, frequent pulse in, 207 
fatty degeneration of, Cheyne-Stokes' respi- 
ration in, 82 
hypertrophy of. See Hypertrophy. 

compensatoiy, 169 

other than valvular, 170 

tympanitic resonance in, 112 
inspection and palpation of, 1 71 
left, enlargement of, smallness of Traube's 

space in, 275 
•liver boundary, 294 
movement of blood in, 167 
-murmur, presystolic, 194 

systolic, heard over carotid, 222 
-murmurs, anemic, 197 

combination of several, 196 

differentiation of, 196, 197 

endocardial, loudness of, 195 

inorganic, 197 

localization of, 192 

organic, 191 

organic endocardial, 191 

relation of, to time of heart's action, 192 

transmission of, 196 
neuroses, pain in, 526 
percussion of, 177 
physiology of, 167 
position of, in thorax, 166 
prominence in neighborhood of, 175 
pulsation in region about, 176 
pulsations at base of, 176 

palpation for, 90 
relation between size of, and parietal por- 
tion, 170 
relation of, to nervous disease, 526 
simple dilatation of, 170 



Heart-sounds, divided, 190 
double, 190 
metallic, 191 
normal, 183-187 

variations in, 186 
pathological changes in, 187 
rhythm of, alteration in, 189 
strengthening of, 187 
tone of, variations of, 187 
tones of, 183 
weakness of, 189 
Heat and cold, sense of, testing of, 440 

sensations of, 526 
" Heaving" of apex-beat, 174 
Hectic fever, 61 

redness in tuberculosis, 37 
Hegar on injection of water in palpation of 

rectum, 280 
Heger-Kaltenbach, palpation of ureters 

through vagina, 359 
Heller's test for blood in urine, 400 

for hemin, 330 
Hematemesis, 328 
Hematin in solution, test for, 399 
Hematochyluria, 250 
Hematoidin crystals in sputum, 147, 155 

in urine, 389 
Hematoma of dura, inequality of pupils in, 

.517 
Hematuria, 375 

albumin with, 399 

blood-casts a sign of hematuria, 382 

caused by filaria sanguinis hominis, 383 

coloring-matter of blood in urine in, 370 

due to strongylus gigas, 382 

fibrin in urine of, 398 

when occurs, 375 
Hemialbumose in urine, 394, 398 
Hemianesthesia, hysterical, unilateral pale- 
ness in, 526 

in gross hysteria, 491 

when occurs, 443 
Hemianopsia, 521 

homonymous, 521 

how produced, 421 

light-reaction of pupil in, 519 

schematic representation of, 520 
Hemianoptic pupil rigidity, 519 
Hemiathetosis, 492 
Hemichorea, 492 
Hemicrania, unilateral paleness or redness in, 

526 
Hemidrosis, 33, 34 
Hemin in urine, test for, 400 

-test for blood in vomit, 330 
Hemiopia, how produced, 421 
Hemiplegia alterans, 453 

cruciata, 453 

seu alterans, 425 

decubitus acutus in, 530 

defined, 452 

deforming arthritis in, 531 

dorsal flexion of foot in, 492 

due to lesion of internal capsule, 425 

stiffness of joints in, 531 
Hemisystole, double, positive venous pulse in, 
229 



INDEX. 



575 



Hemisystolia, 175 

Hemoglobin, alteration of percentage of, in 
anemia and chlorosis, 238 

casts of, in urine, 382 

in blood, determination of amount of, 233 

in urine, appearance of, 377 

tests for, 399 
Hemoglobinemia, coloring-matter of blood in, 

370 

recognition of, 233 

spectroscopic examination of blood in, 235 
Hemoglobinometer of Gowers, 234 
Hemoglobinuria, albumin with, 399 

appearance of urine in, 377 

coloring-matter of blood in urine in, 370 

paroxysmal, 371 
Hemo-hepatogenous icterus, 41 
Hemometer of Fleischl, 234 
Hemophilia, hematuria in, 376 
Hemoptysis, 146 
Hemorrhage, amaurosis after, 548 

cystic, appearance of blood in urine from, 
376 

from intestine, bloody stools in, 338 

from lungs, 146 

starch-corpuscles in sputum of, 155 

from stomach, blood mixed with feces in, 

339 
location of source of, in hematuria, 376 
microcythemia after, 240 
of kidney, spirillum recurrens in urine of, 

385. 

of lungs, diagnosis of, 146 

of pons or oblongata, effect of, 425 

of skin in hysteria, 529 

of stomach, bloody vomit in, 329 
odor of vomit in, 332 

retardation of pulse ia, 204 

retinal, 547, 548 

renal, appearance of blood in urine of, 376 

subnormal temperature with, 57 

symptoms of, 36 
Hemorrhages, cutaneous, 45 

disturbance of consciousness from, 437 

into subcutaneous tissue in epilepsy, 530 

in the skin, 45 

in the skin, distinguished from inflamma- 
tion, 45 
Hemorrhoids, hemorrhage from large intestine 
in, Z'i'^ 

pain at stools with, 335 
Hepatitis, diffuse, enlargement of liver in, 289 

interstitial, surface of liver in, 291 
Hepatization of lung, resonance over, 109 
Hepatogenous icterus, 40 
Hereditary disease, 20 
Heredity, 20 

Hering's spectroscope, 235 
Herpes facialis, 44 

labialis, 45 

nasalis, 45 

nervous origin of, 529 

zoster, when occurs, 529 
Herringhamon cyclic albuminuria, 396 (note) 
Heubner on detection of metallic percussion- 
sound, 99 

rod-pleximeter, percussion of, 1 17 



Hiccough, 496 

High percussion-sound, 95 

Hippocratic succussion, 133 

Hissing riles, significance of, 128 

History, clinical, defined, 17 

Hoffmann (F. A.), on hemosiderin, 151 

Hoffmann's test for perception of form, 446 

Hofmeier on cause of icterus neonatorum, 42 

Holz on ascending venous pulse, 229 

on cultures of bacillus of typhoid fever, 550 
Homonymous hemianopsia, 521 
Hooke, reference to, 118 
Hoppe-Seyler on fatty acids in sputum of 

gangrene of lungs, 164 
Horseshoe kidney, 356 
Hour-glass crystals in urine, 388 

stomach, recogniticm of, by inflation, 272 
Huber on unreliability of Ewald's salol 

method, 322 
Hiibner, congo-red test for hydrochloric acid, 

316 
Humming sounds, significance of, 128 

venous, 230 
Hiirthle on the "recoil" of the pulse-curve, 

212 
Hutchinson's spirometer, 141 
teeth, 253 
triad, 253 
Hyaline casts, 380 

chemical nature and origin of, 381 
granular, 381 
staining of, 380 
Hydatid thrill, 292 

vibration with echinococcus of kidney, 358 
Hydremia, 36 

albuminuria with, 394 
edema in, 47 
leukocytosis in, 242 
polyuria in, 366 
Hydrobilirubin in urine, 42 
Hydrocephalus, anosmia in, 524 
choked disk in, 547 
enlargement of cranium in, 430 
falling forward of head in, from weakened or 

paralyzed muscles, 495 
how distinguished from rachitic, 431 
Hydrochloric acid, antiseptic and peptic 
power in digestion, 307 
diminished secretion of, effect on diges- 
tion, 308 
in stomach, deficiency of, determination 
of, 320 
determination of, 316 
tests for, 316-321 
value of, 318 
increased secretion of, 309 
masked, 306 

of stomach, function of, 305 
period of digestion, 306 
Hydronephrosis, palpation of, 358 
temporary flow of urine after, 367 
tenderness with, 357 
Hydropericardium, area of heart-dulness in, 
184 
weakened heart-sounds in, 189 
Hydropneumothorax, exploratory puncture in, 
136 



576 



INDEX. 



Hydropneumothorax, splashing in, 133 
Hydrops mechanicus, 47 

vesicas felleae, 292 
Hydrothionic urine, 373 

Hydrothorax, boundaries of percussion-dead- 
ness in, ill 
exploratory puncture in, 136 
Hypacidity, microscopic appearance of 
stomach-contents in, 316 
of stomach, significance of, 324 
varying significance of, 324 
Hyperacidity, microscopic appearance of stom- 
ach-contents in, 316 
of stomach, 308, 309 

relative, 310 
significance of, 325 
Hyperesthesia, 443 

ovarian, 529 , 

Hyperidrosis, 2)Z 
localis, 33 
universalis, 33 
Hypermetropia, inequality of pupils in, 517 
Hyperosmia, 524 
Hypei-pyretic fever, 55 
Hyperpyrexia, 55 

Hypersecretion of gastric juice, 31 1 
significance of, 325 
vomit in, 328 
of stomach, acid gastric juice after test- 
breakfast, 323 
Hypertrophic liver, surface of, 291 
Hvpertrophy of heart, area of heart-dulness, 
180 
compensatory, 169 
other than valvular, 170 
pulse in, 210 
of left ventricle favors hemorrhage and 
valvular endocarditis, 526 
from nephritis, 170 
from sclerosis of arteries, 170 
idiopathic, 170 
large pulse in, 208 
pulsation of aorta in, 218 
of muscles, 453, 456 
of right ventricle from emphysema, 170 

strengthened pulmonary sound in, 188 
of stomach, peristaltic motions in, 272 
Hypesthesia, 442 
Hyphidrosis, 33 
Hypnosis, catalepsy in, 492 
Hypochondria, oxalate of lime in urine of, 

389 

phosphaturia in, 389 
Hypochondrium defined, 268 

illustrated, 269 
Hypogastrium defined, 268 

illustrated, 269 

right, in enlargement of liver, 288 
Hypoglossus, course of, 418 

motor center for, 416 

peripheral paralysis of, speech disturbance 
in, 502 

tract, 418 
Hysteria, active spasms in, 456 

ageusis in, 524 

allochiria in, 443 

anesthesia of pharynx in, 527 



Hysteria, anuria in, 528 

catalepsy m, 492 

central vomiting in, 326 

concentric nan-owing of field of vision in, 
521 

dyspnea in, 526 

epithelial cells in bloody sputum of, 151 

gross, 491 

headache in, 447 

hemianesthesia in, 443 

hemorrhage of skin in, 529 

hypersecretion of gastric juice in, 325 

importance of disease of female genitals as 
a cause of, 529 

increased tendon-reflexes in, 461 

laryngeal paralysis in, 525 

loss of voice in, 495 

nervous cough in, 525 

oliguria in, 528 

palpitation and pain of heart in, 526 

paralysis of larynx in, 68 
of laryngeal muscles in, 541 
of thyreo-arytaenoideus in, 542 

polyuria in, 528 

raspberry sputurn in, 146 

retardation of pulse in, 204 

sensibility of cranium to pressure, 433 

sensitiveness of spine to pressure in, 434 

severe, 491 

tonic spasms in, 490 

tremor with, 489 

urinary disturbances in, 528 

vasomotor disturbances in, 526 

vomiting with, 527 
Hysterical convulsions, 491 

dumbness, 502 

hemianesthesia, unilateral paleness in, 526 
Hystero-epilepsy, 491 

cyanosis in, 39 
Hysterogenous zones, 529 
in gross hysteria, 491 
Hystero-traumatic neuroses, analgesia in, 444 

Icteric casts in urine, 380 

urine, 371 
Icterus, 40. See also Jaundice. 

bile-pigment in urine of, 371 
in sputum in, 147 

casts in urine in, 380 

catarrhal, oxalate of lime in urine of, 381 

color of urine in, 371 

from dissolution of blood by poisons, 41 

hemo-hepatogenous, 41 

hepatogenous, 40 

color of stools in, 337 
retardation of pulse in, 204 

neonatorum, 42 

of stagnation, 40 

urobilin, 42 
Idiocy, 438 

Idiomuscular contractions, 485 
Idiopathic migraine, 447 

neuralgia, 447 
Idiotism, increased secretion of saliva in, 527 
Ileo-psoas, paralysis of, effect of, 500 
Ileus, 330 

odor of vomit in, 332 



INDEX. 



577 



Iliac fossa, right, pain on pressure over, 277 

Imagination, examination of, 437 

Imbecility, 438 

Inactivity, atrophy from, 453 

Inanition, acetone in urine in, 409 

retardation of pulse in, 204 
Incisura cardiaca and parietal relation of 
heart, 17 1 
boundaries of lungs at, 106 
Incompensation of heart, 189 
Incontinentia alvi, 335 

in nervous disease, 527 

urinse, 528 
Increased irritability, significance of, 485 
Incubation period defined, 22 
Indican, abnormal amount in urine, 369 

in urine, test for, 369 

of urine, 363 
Indicanuria, 369 
Indifferent electrode, 462 

method of using, 467 
Indirect irritation, 466 
Individual diagnosis, 18 
Indoxylsulphuric acid in urine, 409 
Infantile paralysis, muscular hypertrophy in, 

456 
Infarction, hemorrhagic, Curschmann's spirals 

in, 155 

of kidney, hematuria in, 375, 376 
intestinal, 338 

of lungs, bronchial breathing in, 125 
friction-sounds in, 133 
hemorrhage in, 146 
percussion-sound in, loi 
of spleen, enlargement of organ in, 298 

tenderness in, 298 
pulmonary, crepitant rales in, 131 
Infectious diseases, 20 

acute, delirium in, 438 

disturbance of consciousness in, 437 
headache with, 447 
breathing in, 81 

Cheyne-Stokes' respiration in, "^Tt 
enlargement of liver in, 289 
fever in, 57 
glycosuria in, 403 
hemoglobinuria in, 370 
tenderness of spleen in, 298 
influence, neuralgia from, 447 
Inflated thorax, 75 
Influenza bacillus, 552 
Infrascapular space, 69 
Infraspinatus muscle, function of, 498 
Infratrochlear nerve illustrated, 448 
Infusoria in feces, 353 

in sputum, 158 
Inguinal region defined, 268 

illustrated, 269 
Inherited diseases, 20 

tendency, 20 
Inorganic murmurs, 197 

sediments in urine, 385 
Inosite in urine, 406 
Insanity, superacidity in, 325 

spermatorrhea, 414 
Inspiration, auxiliary muscles of, 86 
Inspiratory dyspnea. See Dyspnea. 

37 



Insufficiency, aortic, character of murmurs in, 

195 

diastolic murmur in, 193 

increased pulsation in arteries, 221 

liver-pulse in, 228 

pathological sound over arteries in, 22 

pulsating tumor of spleen in, 298 

pulsation of aorta in, 208 

pulse-curve in, 214, 215 

quick pulse in, 209 

weakening of first sound at apex in, 
189 
caused by endocarditis, 168 
mitral, division of second apex-sound in, 
190 

murmurs in, character of, 195 

pulse in, 2i6 

systolic murmur in, 193 
murmur of, 192 

of aortic valve, effects of, 168, 169 
of heart valves, murmurs in, 191 
of mitral valve, effect of, 168, 169 
of pulmonary valve, effects of, 168, 169 
of stomach, determination of, by test-meal, 

314 

food in stomach after digestion of test- 
breakfast, 323 
of tricuspid valve, effect of, 168, 169 
pulmonary, diastolic murmur in, 193 

pulse in, 217 
relative valvular, 168 
tricuspid, positive venous pulse in, 227 
systolic murmur in, 193 
venous engorgement in, 224 
venous sound in, 230 
valvular, and its effects, 168 
Intention tremor, 489 
Intercostal neuralgia, 90 
in tabes, 447 
spaces, systolic drawing in of, 177 
Intermittent fever, 63 

chlorid of sodium in urine increased in, 

392 
herpetic eruption in, 45 
in febrile diseases, 63 
malarial, 63 

range of temperature in, 56 
sweat in, 34 
Internal capsule, blood-supply of, 422 
effect of lesion of, 425 
lesions of, hemianesthesia in, 443 
hemorrhage, 36 
Interscapular space, 69 
Intestinal catarrh. See Catarrh. 

contents, accumulation of, indicanuria in, 

369 

crises, 527 

digestion shown by stools, ^^ZZ 
discharges, pregnancy and character of, 333 
infarction, 338 

parasites as a cause of nervous diseases, 527 
peristalsis, visible, 279 
Intestine, auscultation of, 281 

exploratory puncture of, 285, 286 
occlusion of, indicanuria in, 369 
percussion of, 280 
deep, 281 



578 



INDEX. 



Intestine, small, mistaken for colon, 279 

tumors of, palpation of, 279 
percussion of, 280 
Intestines, examination of, 277 

metallic sound over, 98 

palpation of, 277 

tenderness of, 277 
Intoxications, retardation of pulse in, 204 
Intussusception of intestine, obstipation in, 

334 
Invagination of intestine, obstipation in, 334 
lodid of potassium in saliva, 256 
lodin in urine, test for, 410 
Iron dust in sputum, 147 
Irrigation of rectum, 286 
Irritability, diminished, significance of, 484 

increased, significance of, 485 

qualitative, of muscles, 478 
Ischiatic nerve, electric stimulation of, 472 
Ischuria paradoxa, 528 
Itching in jaundice, 41 

Jackson's epilepsy, 490 

Jaffe on fatty acids in sputum of gangrene of 

lungs, 164 
Jaquet's sphygmograph, 211 
Jaundice, 40. See Icterus. 

caused by ascaris lumbricoides, 343 
from gall-stones, 339 
itching in, 41 
sweat in, 34 
Jendrassik on examination of foot-phenome- 
non, 461 
Johann Faber's dermatograph, value of, 133 
Johnson on picric-acid test for albumin in 

urine, 395 
Johnson's modification of Widal test, 247 
Joint-disease in diseases of nervous system, 
530 
neuroses, 531 
Joints, chronic diseases of, atrophy with, 455 
Jolly on contraction of myotonic muscles, 484 
Jonas and Benczur. See Benczur and Jonas. 
Jugular vein, abnormal fulness of, 223, 224 
phenomena of circulation in, 225 
valvular sound in, 227 
Jurasz on " cerebral blowing," 222 

Kahler on hemialbumose in urine, 398 
Kannenberg on spirillum recurrens in urine, 

385 
Karlinski on bacillus enteritidis, 554 
Kast on effect of absence of hydrochloric 
acid from gastric juice, 325 
on fermentation-test for sugar, 404 
Kidney, amyloid, hyaline casts in urine of, 
380 
contracted, casts in urine in, 374 
edema with, 399 
gallop-rhythm in, 191 
hard pulse in, 210 
hyaline casts in urine of, 380 
polyuria in, 366 
retinitis albuminurica in, 547 
-disease, dropsy of, 398 
engorgement of, casts in urine of, 380, 381 
lateritious sediment in urine, 387 



Kidney, exclusion of one, polyuria from, 36 
fatty. See Fatty kidney. 
floating, 358 
horseshoe, 356 

injuries to, hematuria from, 375 
large white, adipose elements with renal 
casts in urine of, 381 
edema with, 399 
fat in urine of, 378 
renal epithelia in urine of, 379 
movable, 358 
percussion of, 358 
tumors of, detection of, 357 
wandering, 357 
Kidneys, anatomy of, 355 

engorgement of, albuminuria in, 394 
examination of, 355 
inspection of, 356, 357 
palpation of, 356, 357 
percussion of, 356 
tenderness on palpation, 357 
Kissing as a source of bacterial infection, 257 
Kistermann on bismuth-test for sugar, 402 
Kitasato, direct culture of tubercle bacilli, 

162 
Klemperer on course of separation of albu- 
mins in urine, 396 
Klemperer's oil method for determining ra- 
pidity of evacuation of stomach - 
contents into duodenum, 322 
Knee-phenomenon, 459 
Knife-blade crystals in urine, 389 
Knoll's rubber bottle, 141 
Knowledge of form, testing of, 446 
Koch's tuberculin, effect of, on sputum of 
tuberculosis, 162 
use of, in diagnosis, 164 
Kosselt on peptone in sputum, 164 
Krehl on heart-sounds, 184 

on "recoil" of pulse-curve, 212 
Kiilz on casts in urine of diabetic coma, 380 

on oxybutyric acid in urine of diabetes, 407 
Kussmaul on ataxic aphasia, 506 

on congenital displacement of pylorus, 271 
on eftect of respiration on jugular veins in 

mediastino-pericarditis, 226 
on the tract for speech-motions, 505 
"peristaltic unrest" of stomach, 272 
word-deafness, 506 
Kussmaul's test-meal, 312 
Kuttner on use of illuminating sound to in- 
troduce water into stomach, 277 
Kyphoscoliosis, 78 

a cause of hypertrophy of right ventricle, 

170 
dyspnea in, 85 
spleen can be felt in, 298 
Kyphosis, 78 

acute-angled, effects of, 434 

from paralysis of erector trunci, 495 

Laache on leucin and tyrosin in urine of per- 
nicious anemia, 390 
Lachrymal nerve illustrated, 448 
Lactalbumin in digestion, 306 
Lactic-acid fermentation in digestion, 305 
in stomach, determination of, 318 



INDEX. 



579 



Lactose in urine, 406 

Laennec, developed auscultation, 1 18 

reference to, as user of percussion-hammer, 

93 
Laennec's pectoriloquy, 135 
" Lagging," detection of, by palpation, 91 
Lagophthalmus, 493 
Lalopathy, 502 
Landerer on cause of edema, 48 

on constant circumscribed tenderness in 
gastric region, 273 
Laryngeal catarrh, signs of, 538 
crises, 525 
fremitus, 67 
mirror, 535 

muscles, functions of, 494 
paralysis of, 494 
Laryngitis as a symptom of disease, 68 
hypoglottica, 538 
paralysis of thyreo-arytaenoideus internus 

in, 542 
paralysis of arytsenoideus transversus in, 

541 

phlegmonous, 539 

swelling of larynx in, 538 
Laryngoscopic image or view, 536 
Laryngoscopy, 535 

instruments for, 535 

sources of light in, 535 
Larynx, abnormal redness of mucous mem- 
brane of, 538 

carcinoma of, 541 

casts of, 149 

examination of, 67 

fibroma of, 541 

gummata of, 540 

laryngoscopic examination of, 535 

motor center for, 416 

movements of, 537 

new formations of, 541 

normal color of, 537 

percussion-sound over, 105 

paleness of mucous membrane of, 537 

papilloma of, 541 

paralysis of, 68 
of muscles of, 541 

pathological conditions of, 537 

relation of disease of, to nervous disease, 

525 
sarcoma of, 541 
scars of, 540 
spasm of muscles of, 541 
stenosis of, 67 
symptoms of disease of, 68 
swelling of, when occurs, 538 
syphilitic infiltration of, 540 

ulceration of, 539 
tubercular ulceration of, 54O 
tympanitic sound over, 97 
ulceration of, 539 
cough in, 143 
Lateritious sediment of urine, 363 
Latissimus dorsi, paralysis of, testing of, 498 
Laveran's bodies in malarial blood, 247 
Law of contraction, 478 
Lead colic, hard pulse in, 210 
pulsus tardus in, 210 



Lead colic, scaphoid abdomen in, 279 
in urine, 411 
-paralysis, effect of, 498 

reaction of degeneration in, 484 
-poisoning, black vomit in, 328 
chronic, teeth and gums in, 253 
headache in, 447 
neuralgia in, 447 
Leanness, significance of, 31 
Leg, motor center for, 417 

paralysis of muscles of, 500, 501 
Lenticular nucleus, blood-supply of, 422 

disease of, in chorea, 492 
Leo on evacuation of milk from stomach of 
infants, 357 
on prevention of fermentation in stomachs 

of nurslings, 307 
on stomach-digestion of nurslings, 308 
Lepra bacillus, 552 
Leptothrix buccalis in saliva, 257 
in sputum, 150, 158 
in urine, 385 
in pharynx, 263 
Lethargic stage of hypnosis, over-excitability 

of nerves and muscles in, 486 
Letzerich and Berger, microbe of whooping- 
cough, 164 
Leube's method of obtaining gastric secretion, 

323 
test-meal, 312 
Leucin in urine, 390 
Leuckart on taenia cucumerina in children, 

.343 
Leukemia, albuminuria in, 394 

ascending venous pulse in, 229 

diminution of red corpuscles in, 238, 244 

enlargement of spleen in, 298 

hematuria in, 376 

hemorrhage from fundus of eye in, 547 

leukocytes in, 242 

lienal-myelogenous, leukocytes in blood of, 
242 

lymphatic, blood in, 244 

myelogenous, 242 

paleness in, 36, 37 

retinal, changes in, 547 

surface of spleen in, 299 

tumors of spleen in, 298 

uric acid increased in, 392 
Leukocytosis, 242 

cachectic, 242 

hydremic, 242 

inflammatory, 242 

physiological 242 
Levulose in urine, 406 
Levator anguli scapulae, paralysis of, effect of, 

497 
Levy on effect of presence of Frankel's 

pneumococcus in pleural exudates, 

138 
Lewis and Miller on bacillus resembling 

comma bacillus in tooth-mucus, 351 
Leyden, hemisystolia, 175 

on double positive venous pulse in hemi- 

systole, 229 
on fatty acids in sputum of gangrene of 

lungs, 164 



58o 



INDEX. 



Leyden on tyrosin in sputum, 157 
Lichtheim on edema, 47 

on mental condition in atactic aphasia, 507 
Lichtheim's diagram of aphasia, 511 
Lieben on test for acetone in urine, 409 
Liebermeister on pulse in fever, 205 

on testing the accuracy of a thermometer, 

51 

Lientery stools, 337 

Life, manner of, in the causation of disease, 

21 
Light reflex of pupil, 518 

rigidity of pupil, 518 
Lime-salts in feces, 349 
Linea costo-articularis, 296 
Lipaciduria, 407 
Lipemia, 245 

Lipomatosis cordis, weak apex-beat in, 174 
Lips, examination of, 253 
Lipuria, 372, 406 
Literal agraphia, 513 

aphasia, 507 
Litten on casts of micrococci in ui-ine, 385 

on diaphragmatic phenomenon, 74 
Liver, abscess of, tenderness in, 290 

acute yellow atrophy of, cutaneous hemor- 
rhage in, 46 
affections of urobilinuria in, 369 
anatomy of, 286 

biliary engorgement of, tenderness in, 290 
cancer-navel upon, in carcinoma, 292 
carcinoma of, tenderness in, 290 
cirrhosis of, tenderness in, 290 
consistence of, in various diseases, 292 
constricted, palpation of, 290 
downward displacement of, 288, 289, 291 
dulness, 292, 292 

displacement of boundaries of, 294 
relative, 108 
engorged, increased consistence of, 292 
engorgement of surface of, 291 

of, tenderness in, 290 
enlargement of, causes and signs of, 289 
dulness in, 295 
expansion of thorax in, 77 
from general venous engorgement, 224 
liver-pulse in, 289 

projection of right hypochondrium in, 288 
smallness of Traube's space in, 275 
examination of, 286-296 
exploratory puncture of, 292 
form of, 291 

hypertrophic, surface of, 291 
inspection of, 288 
-kidney angle, 355 
lobulated, 291 

mobility of, boundaries of, 294 
palpation of, 289 

pathological relations of boundaries of, 294 
percussion-limits of, 293, 294 
percussion of, 292 
pulse, 221 
arterial, 228 

in enlargment of liver, 289 
palpation of, 228 
venous, 228 
size and form of, 290 



Liver, square position of, 295 

surface of, in various diseases, 291 
syphilitic, tenderness of, 290 
tenderness of, 290 
tumors of, inspection of, 289 
upward displacement of, 289, 295 

dulness in, 295 
wandering, 289 

absence of liver-dulness in, 296 
" Livid skin," 38 

Lobes of the lungs, boundaries of, 72 
Lobulated liver, 291 
Local asphyxia in nervous diseases, 526 
disease, diagnosis of location of, 532 
sense, testing of, 440 
Localization, power of, testing of, 440 
Lofiler's bacillus, determination of, 260-262 
diphtheria bacillus in sputum, 164 
methylene-blue, 262 
Logwood, color of urine, after taking, 371 
Lordosis, 434 
Louis, angle of, 73 

Lowenfeld on contractions in reaction of de- 
generation, 483 
" Luftschlucken," 310 
Lugol's solution, 322 

Lumbar cord, diseases of, residual urine in, 
368 
enlargement of cord, location of, 434 
puncture, 434 
Lumbo-inguinal nerve illustrated, 451 
Lung-cavities, bronchial breathing over, 126 
metallic heart-sound in, 191 
metallic sound over, 98 
plegaphonia over, 135 
tympanitic sound over, 97, 113 
-dyspnea, 85 
-fistula, sound of, 13 1 
-heart boundary, 106 
infiltrated, plegaphonic sound in, 135 
-kidney boundary, 106 
-liver boundary, 106 
sequestra in sputum, 147 
-sound, 95 

-spleen boundary, 106 
thickening of, ringing rales in, 130 
-tissue, decreased tension of, abnormally 
loud percussion-sound in, 1 16 
in sputum, 147 

retracted, cracked-pot sound in, 116 
thickening of, bronchial breathing in, 125 
Lungs, abnormal percussion-sounds over, 109 
abnormal position of border of, 109 
abscess of, shrinking of chest-wall in, 78 
anatomical boundaries of, with reference to 

the thorax, 69 
auscultation of, 118 

compression of, bronchial breathing in, 125 
contraction of, a cause of hypertrophy of 
right ventricle, 170 
drawing-in of side of thorax in, 77 
deadened resonance over, 109 
diminished volume of, recognized by lung 

boundaries, 1 18 
diminution of motility of, 1 18 
diseases of, dyspnea in, 85 
dulness over, 109 



index: 



581 



Lungs, edema of dyspnea in, 85 
examination of, 68 

gangrene of, sliiunken chest-wall in, 78 
hemorrhage of, 146 
infarctions of, percussion resonance in, 

no 
infiltration of, resonance in, no 
non-tympanitic sound over, 99 
normal boundaries of, 105 
percussion boundaries of, 106 
sound of, 105 
percussion of, 103 
shrinking of, a cause of displacement of 

apex-beat, 173 
thickening of, resistance over, 102 
Lupus a cause of catarrh of larynx, 538 
Lustgarten on bacteria in normal urine, 361 
Lymphatic glands of neck, examination of, 

260 
Lymphocytes, 242 
Lymphosarcoma of spinal cord, hemialbumose 

in urine of, 398 
Lysis defined, 61 
Lyssa, increase of tendon-reflexes in, 461 

Macrocephalus, 430 
Macrocytes, 240 

nucleus-containing, 240 
Main en griffe, 499 
Malachowski's method of staining malarial 

parasites in blood, 248 
Malaria, enlargement of spleen in, 298 

fever in, 57 

hemoglobinuria in, 370 

intermittent fever of, 63 

melanemia after, 245 

neuralgia in, 447 
Malarial cachexia, paleness in, 36 

parasites in blood, 247 
Malignant edema, bacilli of, 550 
Mai perforant, 530 
Mammillary lines, 69 
Manegegang, 491 

Mannaberg on Malachowski's staining mala- 
rial parasites in blood, 248 

on bacteria in normal urine, 361 
Marasmus defined, 31 
Marey's pneumograph, 141 
Marie on acromegalia, 53 1 
Martins' method of showing relation of apex- 
beat to heart-cycle, 172 
Mast-cells, 242 

staining of, 245 
Mastication, muscles of, function of, 493 

paralysis of, 494 
Masturbation, spermatorrhea from, 414 
Matterstock, sound over crural artery in lead- 
poisoning, 222 
Maximal thermometers, 51 
Measles, acute laiyngitis in, 68 

acute nasal catarrh in, 66 

cutaneous hemorrhage in, 46 

entrance of, through tonsils, 258 

epileptiform convulsions in, 490 

recurrence of, 22 
Measurement, methods of, 140 
Meat-poisoning, bacillus enteritidis in, 554 



Mechanical excitability of muscles and nerves. 

Mediastinal emphysema, crepitation of, 200 
pericarditis, systolic drawing in of intercostal 

spaces m, 177 
tumors a cause of cyanosis, 38 

of displacement of apex-beat, 173 
venous engorgment from, 224 
Mediastinitis, fibroid, diastolic collapse of cer- 
vical veins in, 229 
effect upon venous circulation, 226 
Mediastinopericarditis, effect of respiratory 

motions on jugular veins in, 226 
Medicines, discoloration of urine from, 371 

which cause polyuria, 367 
Medulla oblongata, disease of, salivation in, 
256 
softening of, recurrent paralysis in, 543 
Mel3ena neonatorum, bloody vomit in, 329 
Melancholia attonita, catalepsy in, 492 
Melanemia, 245 
Melanosis, arsenical, 43 
Melas-icterus, 40 
Mellituria, 367 
Memory, testing of, 436 

Meniere's disease, tinnitus aurium with dizzi- 
ness in, 523 
Meningitis, albumin in cerebrospinal fluid in, 

435 
anosmia in, 524 
breathing in, 81 
catalepsy rare in, 492 
central vomiting in, 326 
cerebrospinal, temperature with, 64 
Cheyne-Stokes' respiration in, 82 
choked disk in, 547 
disturbance of consciousness in, 437 
fibrin in cerebrospinal fluid in, 435 
from disease of ethmoid bone, 525 
hard pulse in, 210 
headache in, 446 
herpes with, 45 
irregular fever in, 64 
metastatic, Frankel's pneumococcus in, 

163 
neuroretinitis in, 547 
opisthotonos in, 29 
pain in spine in, 447 
posture in, 29 
pulse in, 210 

purulent, pus in cerebrospinal fluid in, 435 
rigidity of neck in, 434 
scaphoid abdomen in, 279 
sensibility of cranium to pressure in, 433 
sensitiveness of spine to pressure in, 434 
spinal, rigidity of spinal column in, 474 

herpes zoster in, 529 
tuberculous, bacilli in cerebrospinal fluid in, 

435 
Mental disease, hemidrosis in, 34 

exertion, glycosuria in, 402 
Mercurial poisoning, salivation of, 256 
Mercury in urine, 41 1 

poisoning, glycosuria in, 401 
headache in, 447 
looseness of teeth in, 253 
neuralgia from, 447 



582 



INDEX. 



Mesocardia, 182 
Mesogastrium defined, 268 

illustrated, 268 
Metallic after-sounds, 98 

heart-sounds, 191 

murmurs, 196 

pericardial splashing, 200 

rales, 128 

sound, 98 
Metamorphosing breathing, 127 
Metapneumonic exudations, micro-organisms 

in, 138 
Meteorism, absence of liver-dulness in, 296 

expansion of thorax in, 77 

metallic heart-sounds in, 191 

percussion-sound in, 280 
Meteorismus peritonei, 281 

recognition by percussion, 284 
Methemoglobin in blood in poisoning with 
chlorate of potash, 236 

in urine, 400 
Methyl-violet test for hydrochloric acid in 

stomach, 317 
Microbe of whooping-cough, 164 
Microcephalus, 431 
Micrococci, casts of, in urine, 385 
Micrococcus gonorrhoeae, 549 
staining of, 549 

tetragenus, 159 

ureae causes alkaline fermentation of urine, 

liquefaciens causes alkaline fermentation 
of urine, 383 
Microcytes, 240 
Microcythemia, 240 

Micro-organisms in blood, staining of, 247 
in feces, 349 
in mouth, 257 

in pleural exudations, examination for, 137 
in urine, 361 
Microscopic examination of blood, 237 
of feces, 347 
of mouth-contents, 256 
of sputum, 150 
Micturition, difficult, a cause of diminished 

quantity of urine, 368 
Miescher's improved blood-mixer, 244 
Mietz on determination of free hydrochloric 

acid in stomach, 319 
Migraine, 447 

from tinnitus aurium, 523 

hemidrosis in, 34 

hyperacidity in, 325 

inequality of pupils in, 517 

polyuria in, 367 

subjective sensation of light in, 522 

unilateral paleness or redness of head in, 

526 
vomiting with, 527 
Migrene ophthalmique, 522 
Miliaria, 45 
Milk-curdling ferment, secretion of, 306 

particles of, in sputum, 150 
Mind, condition of, mode of examining, 436 
Minimal contraction, 473, 475 
Minkowski on oxybutyric acid as a cause of 
diabetic coma, 407 



Minkowski's researches on formation of bile- 
pigment in geese and ducks, 40 
Miserere, 330 
Mitral insufficiency. See Insufficiency. 

disease, heart-disease cells in sputum of, 
152 
venous engorgement in, 224 

stenosis. See Stenosis. 

valve, auscultation of sound of, 184, 185 
Moist cough, 143 

rales, 129 
Monas in sputum, 158 
Monocrotic pulse, 213 

Monoplegia accompanying Jackson's epilepsy, 
491 

defined, 452 

from lesion of corona radiata, 425 
Moore's test for sugar in urine, 403 
Morbus Werlhofii, hematuria in, 376 
Morenheim's depression, 68 
Moritz on action of stomach, 307 

on constituents of urinary crystals, 386 

on the error of Reuss's method of esti- 
mating albumin, 140 

on fermentation-test for sugar, 404 

on free hydrochloric acid in digestion, 306 

on glycosuria, 402 

on interrupted Wintrick's change of sound, 

114 
on sugar in urine in health, 366 
Morphia, effect of, on pupil, 517 

-poisoning, glycosuria in, 401 
Morphin in urine, 41 1 

-poisoning, Cheyne- Stokes' respiration in, 
83 
Motility, disturbances of, 452 
Mossoon Cheyne-Stokes' respiration inhealthy 

sleep, 83 
Motor activity of stomach, diminution of, 309 
aphasia, 507 
points, 469 

of head and neck, 469 
on arm, 470, 471 
on leg, 474 
on thigh, 472 
upon back of leg, 473 
speech-center, location of, 505 
tracts and centers, 416 
tract, central, 416 
peripheral, 418 
Mould in sputum, 164 
Mouth-contents, bacteria in, 257 

microscopic examination of, 256 
examination of, 252 
floor of, examination of, 255 
mucous membrane of, examination of, 255 
odor from, importance of, 252 
tympanitic sound over, 97 
Movable kidney, 358 
Mucin in urine, 399 
test for, 393 _ 
-like substance in urine, 393 
Mucopurulent sputum, 145 
Mucous corpuscles in sputum, 150 
in vomit, 331 
membrane of intestine, disease of, poor re- 
sorption of food in, 335 



INDEX. 



583 



Mucous membrane of intestine, shreds of, in 
feces, 340 
of mouth, examination of, 255 
reflexes of, 458 

sputum, 144 

stools, 337 

vomit, 328 
Mucus in stools, 348 

in urine, 375 
.chemical proof of, 375 
Muguet in sputum, 150 
Mulberry calculi, 391 

tongue, 254 
Miiller (F.) on urobilin icterus, 42 

on eosinophilous asthma-cells, 157 

on demonstration of ascitic fluid, 284 

on effect of carcinoma on secretion of hy- 
drochloric acid, 325 

on formation of urobilin in intestines, 43 

on imperfect absorption of fat in enteritis, 354 

on quantity of fluid in bladder needed to 
give dulness on percussion, 360 

on resorption of food in enterids, 335 
Multiple neuritis. See Neuritis. 

sclerosis. See Sclerosis. 
Murexid test for uric acid, 387 
Muriatic acid. See Hydrochloric acid. 
Murmur, double, over arteries, 222 

of insufficiency, 192 

subclavian, 222 

venous, 230 
Murmurs, anemic, 197 

combination of several, 196 

diastolic and systolic, 193, 196, 197 

differential diagnosis between pericardial 
and endocardial, 199 

differentiation of, 196 

of inorganic from organic, 198 

endocardial, 19 1 

inorganic, 197 

loudness of, 195 

metallic, 196 

pericardial, 198 

that may be felt, 196 
Musca vomitoria, larva of, in urine, 383 
Muscles, active spasm of, 456 

auxiliary, of inspiration and expiration, 86 

diminution of volume of a symptom of de- 
generation of motor tract, 425 

electrical examination of, 462 

electric stimulation of, 468 

mechanical excitability of, 485 

motor points of, 469 

of face, function of, 492 

of larynx, paralysis of, 541 

of mastication, paralysis of, 494 

of throat and neck, functions of, 495 
paralysis of, 495 

of tongue, functions of, 494 

of upper extremity, 496 

rigidity of, 456 

supplied by radial nerve, electrical exam- 
ination of, 475 

voluntary, innervation, function, and dis- 
eases that disturb them, 492 
Muscular dystrophia, 455 

sense, testing of, 444 



Musculospiral nerve, paralysis of, 451 
Musical notes, conception of, 504 
Muttering delirium, 438 
Mydriasis, 517 
Myelitis, allochiria in, 443 

decreased tendon-reflexes in, 461 
transversa, clonic spasms in, 490 
cystitis in, 528 

extreme atrophy of legs in, 454 
increased tendon-reflexes in, 461 
involuntary discharge of urine in, 528 
Myocarditis, arhythm in, 207 

fibroid, retardation of pulse in, 204 
heart-disease cells in sputum of, 152 
pulse in, 217 

weakened apex-beat in, 174 
Myosis, 517 

Myositis ossificans, cyanosis in, 39 
Myotonia congenita, 483 

increased mechanical excitability in, 485 
tonic spasms in, 490 
Myotonic reaction, 483 

Nails, anomalies of, in peripheral paralysis, 

530 
Naphthalin, color of urine after taking, 371 

in urine, 411 
Nasal mucous membrane, disease of, anosmia 
from, 524 
polypi, relation of, to nervous disease, 525 
septum, appearance of, 543, 544 
sound, use of, 544 

specula, varieties of, 543 
Naunyn, after-sensibility, 443 

and Minkowski, researches on formation of 

biliary pigment in ducks, 40 
on fever from injury of cervical spinal cord, 

525 

on murmur of mitral insufficiency, 192 
Negative venous pulse, 226 
Neisser on diagnosis of gonorrhea, 384 
Nephritis a cause of hypertrophy of left ven- 
tricle, 170 

acute, bacteria in urine in, 385 

albuminuria in, 394 

anuria in, 368 

character of pus-sediment in, 378 

chlorid of sodium in urine diminished in, 
.392 

cyclic albuminuria in, 396 

cylindroids in urine of, 375 

decrease of hydrochloric acid in stomach 

in, 324 
diminished urea in urine of, 392 
diminution of phosphate in urine of, 392 
edema in, 47, 48 
epithelial casts in urine of, 382 
erysipelatous cocci in urine of, 385 
granular casts in urine of, 382 
hematuria in, 375 

infectious, entrance of, through tonsils, 258 
low specific gravity of urine in, 372 
mucin in urine of, 399 
nucleo-albumin in urine with, 399 
odor of vomit in, 332 
pulse-tracing in, 212 
renal epithelia in urine of, 379 



5^4 



INDEX. 



Nephritis, retardation of pulse in, 203 
retinitis albuminurica in, 547 
sequela of scarlet fever, 22 
sweat in, 34 

tenderness over kidney in, 357 
turbid urine in, 371 
urea in saliva of, 256 
white blood-corpuscles and pus in urine of, 

377 
Nephrolithiasis, brick-dust deposit in, 387 

hematuria in, 376 
Nerve, faradic examination of, 473 
Nerves, electrical examination of, 462 

electric stimulation of, 467 

galvanic examination of, 475 

mechanical excitability of, 485 

of head, distribution of, 448 

of lower extremities, distribution of, 451 

of shoulder, arm, and hand, 449 

peripheral, and their surroundings, 436 

sensory cutaneous, distribution of, 448 
Nervous diseases, diagnostic value of symp- 
toms in, 531 
differential diagnosis between functional 

and anatomical, 533 
examination of seat of, 430 

polyuria, 367 

system, anatomy of, 416 
examination of, 414 
Nervousness from intestinal parasites, 527 

hypersecretion of gastric juice in, 325 

palpitation and pain of heart in, 526 

sensibility of cranium to pressure in, 433 

subjective sensibility of hearing in, 523 

syncope in, 438 
Neubauer on specific gravity of urine as a 
guide to amount of solid constitu- 
ents, 372 
Neukirch, explanation of Williams's tracheal 

tone, 106 
Neuralgia, 447 

bradycardia in, 204 

glycosuria from, 402 

in diabetes mellitus, 528 

intercostal, 90 

tenderness of nerve in, 448 
Neurasthenia, cerebral, vertigo in, 438 

facial phenomenon in, 486 

headache of, 447 

pain in spine in, 447 

phosphaturia in, 389 

polyuria in, 367 

retardation of pulse in, 204 

spermatorrhea from, 414 

spinalis, disturbance of genital function in, 

529 
Neuritis, acute degenerative, disunion of 
atrophy and paralysis in, 456 
ataxia in, 488 
in diabetes mellitus, 528 
multiple, bladder disturbances absent in, 
528 
diminished irritability in, 485 
neuralgia in, 447 
optica, 513 

peripheral, a cause of cyanosis, 39 
degenerative atrophy in, 454 



Neuritis, peripheral, herpes zoster in, 529 

quickened pulse in, 526 

reaction of degeneration in, 479, 484 

sensitiveness of peripheral nerves in, 448 

significance of, 546 

thickening of nerve from, 436 
Neuro-fibroma, condition of nerve with, 436 
Neuroma, condition of nerve in, 436 
Neuro-retinitis albuminurica, 547 
diabetic, 547 
when occurs, 547 
Neuroses, frequent pulse in, 207 

increase of tendon reflexes in, 461 

local sweating in, 34 
Neutiophile cells, staining of, 245 
Nicotin-poisoning, headache in, 447 

neuralgia in, 447 

palpitation and pain of heart in, 526 

strengthened heart-beat in, 174 

vertigo in, 438 
Niemeyer's solid stethoscope, 120 
Night-sweats of phthisis, 34 
Nitrobenzol-poisoning, color of blood in, 233 

odor of vomit in, 332 
Nitrozo-indol reaction, value of, 554 
Nocturnal enuresis, 528 
Noma, description of, 255 
Non-tympanitic percussion-sound, 95 

sound, intensity of, 99 
where heard, 99 
Nose, affections of, relation to nervous disease, 

525 
anomalies of, 66 
-bleed, 66 

disease of, migraine in, 447 
examination of, 66 
suppuration of, as a cause of meningitis, 

433 
Nothnagel on mucus in stools, 337, 338 
on staining of micro-organism of feces, 

349 
NothnageFs thermesthesiometer, 441 
Nourishment, food-value of, determination of, 

353 
Nubecula of urine, 363 
Nuclear paralyses, 419 
Nucleo-albumin in urine, 399 
Nutrition as affected by nervous disease, 525 

disturbances of, 453 

examination of, 30 
Nutritional tone of muscles, disturbance of, 

453 
Nylander's test for sugar in urine, 402 
Nymphomania, 439 
Nystagmus, 516 

Obermayer's test for indican in urine, 370 
Obernier on rise of temperature in a person 

running, 53 
Obersteiner, allochiria, 443 
Obliquus inferior, paralysis of, effect of, 516 

superior, paralysis of, effect of, 516 
Oblongata, diseases of, glycosuria in, 402 

effect of lesion of, 425 
Obstipation, 333, 334 

indicanuria from, 369 

large stools after prolonged, 335 



INDEX. 



585 



Obstruction of Eustachian tube, drawing-in 

of ear-drum from, 546 
Occlusion of bowels, fecal vomiting, 330 

of intestine, indicanuria in, 369 
Occupation as a factor in causation of disease, 

21 
Oculomotorius, course of, 418 

total paralysis of, effect of, 516 
Odor from the mouth, 252 

of expectoration, 147 

of sputum, 147 

of stools, 336 

of urine, pathological, 373 
Oidium albicans, coating of tongue by, 255 
Old age, nutrition of skin in, 32 
retardation of pulse in, 204 
Oligocythemia, 238 
Oliguria in hysteria, 528 
Omentum, carcinomatous knots in, 303 

examination of, 302 

shrinking of, in tuberculosis and chronic 
peritonitis, 302 
Onanism, concealed, 20 
Ophthalmia neuroparalytica, 448 
Ophthalmoplegia externa, 516 
Ophthalmoscopy, method .of performing, 546 
Opisthotonos, 434 

a form of tonic spasm, 490 

how produced, 496 

in meningitis, 29 
Optic nerve, atrophy of, mydriasis with, 517 
pressure on, choked disk from, 547 
primary atrophy of, 547 

thalamus, effect of diseases of, 427 

tract, 420 

lesion of, hemianopsia in, 521 
Organic heart-murmurs, 191 
Orthopnea, 29 

effects of, 29 

in phthisis, 29 
Osmic paresthesia, 524 
Osteomyelitis, staphylococcus pyogenes in, 

. . 548 

Otitis, Fraakel's pneumococcus in, 163 
Otoscopy, method of performing, 545 
Ovarian hyperesthesia, 529 
Ovary, painful, 529 
Oxalate of lime in sputum, 157 

in urine, 387 
Oxaluria, 389 

Oxybutyric acid a cause of diabetic coma, 
407, 408 
in urine, 407 
testing for, 408 
Oxygen, deficiency of, a cause of cyanosis, 38 

in blood, diagnostic importance of, 233 
Oxyhemoglobin, absorption-band of, 235 

effect of, on color of blood, 233 
Oxyuris vermicularis, 344 
in urine, 383 

Pain a cause of rapid breathing, 84 
after use of sound in esophagus, 265 
diminution of power of motion from, 452 
electric sensibility to, 441 
gi-adual increase of sensibility to, 443 
in ear from diseased teeth, 523 



Pain in iliac fossa, left, 278 
right, 277 

in peritonitis, 282 

in spine, 447 

mydriasis in, 517 

on palpation of spleen, 298 

on pressure over intestines, 277 

on swallowing in stenosis of esophagus, 
264 

sensibility to, testing of, 441 

spontaneous, 446 

syncope from, 438 

thoracic, caused by pressure, 89 

with the stools, 335 
Painful ovary, 529 
Palate, examination of, 257, 258 

microsco])ical and bacteriological, 260 

lodgement of bacteria in, 257 

soft, innervation of, 494 
Pale skin, 35 
Paleness, 35 
Palpation of arteries, 220 

of liver, 289 

of liver-pulse, 228 

of mouth, 252 

of pulse, 201 

of stomach, 270 

of thorax, 89 

of veins, 223 

of vocal fremitus, 133 
Palpitation, nervous, strengthened heart-beat 

in, 174 
Pancreas, examination of, 302 

extirpation of, a cause of diminished fat- 
digestion, 348 

tumor of, 302 
Pancreatic juice, deficiency of, absorption of 

fats in, 335 
Panizza on origin of epithelium in sputum, 

151 

Papilloma of larynx, 541 
Para-anesthesia, 443 
Paradoxical contractions, 486 
Paragraphia, 513 
Paralysis, 452 

agitans, sensations of heat in, 526 

tremor of, 489 
atonic, 451 
atrophic, 457 
degenerative, 419 
atrophic, 453 

fibrillary contractions in, 490 
. partial reaction of degeneration in, 484 
bulbar, reaction of degeneration in, 484 
central, arrest of growth of bones after, 530 
cerebral facial, 493 

degenerative atrophic, indicated by reaction 
of degeneration, 483 
disseminated, reaction of degeneration 
in, 479 
dissociated, from lesion of corona radiata, 

disturbance of conception of motion m, 446 

examination for, 452 

extent of, 452 

facial, 493 

frequent pulse in, 207 



586 



INDEX. 



Paralysis from affections of cortex of brain, 
436 
increased irritability in, 485 
intermitting general, 485 
nuclear, 419 

of abdominal muscles, effects of, 495 
of accommodation, 515 
of arytsenoideus transversus, 541 
of bladder, 528 

of crico-arytsenoidei postici, 542 
of crico-thyroidei muscles, 543 
of diaphragm, 496 

a cause of cyanosis, 39 
of erector trunci, 495 
of extensor muscles of hand, 498 
of facial nerve, symptoms of, 493 
of hand and fingers, characteristic positions 

in, 499 
of heart, pulse in, 207 
of muscles of arm, 498 

of eye, 5I3» SH 
significance of, 516 

of larynx, 541 

of leg, 500 

of lower extremity, 500 

of mastication, 494 

of shoulder, 496 

of speech, 502 

of trunk and scapula, 497 
of oculomotorius, effect of, 515 
of pharyngeal muscles, 494 
of phrenic nerve, shown by palpation, 91 
of recurrent nerves, 542 
of respiratory muscles, dyspnea from, 85, 

525 
of soft palate, 494 

of stapedius, disturbance of hearing in, 523 
of tensor of vocal cords, 543 
of thyreo-arytsenoideus internus, 541 
of tongue, 494 
phenomena of, 452 
progressive, imbecility in, 439 
mydriasis with, 517 
reaction of degeneration in, 484 
relaxed, as a sign of lesion of cortical 

center, 425 
spastic, 419 

spinal, dorsal flexion of foot in, 492 
unilateral hypoglossal, 494 
vasomotor disturbances in, 526 
Paralytic dementia, disturbance of hand- 
writing in, 513 
thorax, 76 
Paralyzed muscles, tonus of, 456 
Parametritic abscess, pus in urine from, 377 
Parametritis, position in, 30 
Paraphasia, 507 
Paraplegia, inferior, 453 
Parasites, animal, in sputum, 157 
in urine, 382 
of alimentary canal, 340 
intestinal, as a cause of nervous disease, 527 
vegetable, in feces, 349 
in urine, 383 
Parasternal lines, 69 
Paresis, defined, 452 
recognition of, 452 



Paresthesia, 446 

osmic, 524 
Parietal boundaries of organs, determining of, 
102 

cavities, cracked-pot sound in, 116 
Parosmia, 524 
Parotid gland, inflammation and swelling of, 

256 
Paroxysmal tachycardia, 207 
Partial epilepsy, 490 
Patellar reflex, 459 
Pathogenic fungi in stools, 349 
Patient, general examination of, 28 

position, attitude, and posture of, 28 

previous history of, 20 

psychical condition of, 28 
Patients, examination of, 24 
Pectoralis major, paralysis of, testing of, 498 
Pectoriloquy, Laennec's, 135 
Peliosis rheumatica, cutaneous hemorrhages 

in, 46 
Pemphigus, nervous origin of, 529 
Pendulum -rhythm, 190 
Penis, irritation of, effects of, 529 
Penzoldt on crepitation in expiration, 132 

on picric-acid test for albumin in urine, 395 
Penzoldt's method for examining absorption 
in stomach, 323 

modification of Gmelin-Rosenbach test, 401 
Pepsin, diminished secretion of, effect on 
digestion, 308 

secretion of, by stomach, 305 
Peptone, absorption of, by stomach, 307 

in sputum, 164 

in urine, 398 

test for, 322 
Peptonuria, 398 

Perception of movement, testing of, 444 
Percussion, comparative, 104, 105 

difference between weak and strong, 95 

direct, 92 

effect of feeble, 100 

finger-, 93 

general remarks upon, 92 

-hammer, 93 

history and methods of, 92 

immediate, 92 

indirect, 92 

mediate, 92 

of abdomen in disease of peritoneum, 283, 
284 

of esophagus, 267 

of heart, 177 

methods of, 177, 180 

of intestine, 280 
deep, 281 

of liver, 292 

of stomach, 273 

of thorax, 92 

-sound, conditions that determine quality of, 
96 

qualities of, 94 

variation of, in individuals, 105 

three methods of, 93 

to determine parietal boundaries of organs, 
102 

to determine resistance of heart, 180 



INDEX. 



587 



Percussion, topographical, 102 
Perforating disease of the foot, 530 
Pericardial adhesions, absence of apex-beat in, 

175 

exudation, cause of weakening of heart- 
sound, 189 
cyanosis from, 38, 39 
friction-sounds, 198 
murmurs, 198 

distinguished from endocardial, 199 
splashing, 200 
Pericarditis adhesiva, divided second apex- 
sound in, 190 
heart-disease cells in sputum of, 152 
pulsus paradoxus in, 209 
systolic drawing-in of intercostal spaces 
in, 177 
downward displacement of liver, 289 
exudativa, abnormally loud percussion- 
sound in, 116 
area of heart-dulness in, 181 
bulging in neighborhood of heart in, 176 
disappearance of apex-beat in, 174 
effect of, on position of liver, 296 
pulse in, 217 

tympanitic resonance in, 112 
friction-sound in, 199 

mediastinal, systolic drawing-in of inter- 
costal spaces in, 177 
pulse in, 218 

venous engorgement in, 224 
Pericardium, diseases of, paleness in, 36 
distention of, expansion of thorax in, 77 
dryness of, friction-sounds in, 199 
fluid in, effect on heart-dulness, 181 
tuberculosis of, friction-sound in, 199 
Perichondritis arytaenoidea, 540 
laryngea, 540 
pus in larynx from, 539 
Pericystic abscess, pus in urine from, 377 
Perinephritic abscess, detection of, 357 

pus in urine in, 377 
Perinephritis, palpation of kidney in, 358 
purulent, tumor of kidney in, 357 
tenderness with, 357 
Perineuritis, condition of nerve in, 436 
Periosteal reflexes, 460 
Periostitis, neuralgia due to, 447 

of ribs, pain with, 90 
Peripheral irritation, sensitiveness to, 439 
motor tract, 418 
nerves, examination of, 435 

tendon reflexes decreased in disease of, 
461 
neuritis, herpes zoster in, 529 

local asphyxia in, 526 
paralysis, 419 

delayed sensibility in, 443 
sight, testing of, 520 
Peripleuritis, deadening of chest-resonance in, 

112 
Periproctic abscess, purulent stools from, 339 
Periproctitis, pain at stools with, 335 
Perisplenitis, enlargement of spleen in, 298 
Peristalsis, intestinal, visible, 279 
Peristaltic modons in stomach, importance 
of, 272 



Peristaltic unrest of stomach, 272 
Peritoneal cavity, air in, 285 

exudate, anuria during formation of, 367 
fluid, encysted, 283, 284 

examination of, 285 
friction-sound, 285 
Peritoneum, air in, absence of liver-dulness in, 
296 
bands in, after tapping abdomen, 285 
diseases of, inspection of abdomen in, 281 
examination of, 281 
palpation of, through vagina, 283 
Peritonitis, ascites that moves about in, 282 
cause of cyanosis, 39 
Cheyne- Stokes respiration in, 83 
chronic, constipation alternating with diar- 
rhea in, 334 
diagnostic points of, 282 
shrinking of omentum in, 302 
tenderness of liver in, 290 
distention of abdomen in, 278 
expansion of thorax in, 77 
fecal vomiting, 330 
Frankel's pneumococcus in, 163 
from paralysis of intestine, obstipation in, 

334 

hardness of abdomen in, 282 

indicanuria in, 369 

leukocytosis in, 242 

local, the detection of, by palpation, 91 

pain in, 282 

pain on palpation of intestines in, 277 

pulsus tardus in, 210 

purulent, staphylococcus pyogenes in, 548 

subphrenic, defined, 284 
friction-sounds in, 200 

surface of liver in, 291 

tubercular, enlargement of spleen in, 298 

tympanitic sound in, 1 12 

vomiting in, 327 
Perityphlitic abscess, pus in urine of, 377 
Perityphlitis, position in, 30 
Pernicious anemia. See Atieviia. 

hemorrhage in fundus of eye in, 548 
Peroneus nerve, electrical stimulation of, 472 

-paralysis, 501 
Perspiration, 32 

in illness, 33 

insensible, 33 

local, 34 

morl^id alterations of, 33 

of feet, loss of, relation to nervous diseases, 
529 

office of, TyT^ 

qualitative alterations of, 34 
relation of, to nervous disease, 529 
varieties of, t^t. 

Perturbation, critical, 61 

Petechiae, 44, 45 

Pettenkofer's test for bile-acids in urine, 401 

Petters on odors of acetone in urine, 373 

Pfeiffer (R), influenza bacillus, 552 

PflUger's law, 467 

Pharyngeal muscles, paralysis of, 494 

Pharyngomycosis leptothricia, 263 

Pharyngoscopy, 544 

Pharyngosis leptothricia, 263 



588 



INDEX. 



Pharynx, anesthesia of, 527 

examination of, 260 

microscopical and bacteriological, 260 

growth of leptothrix in, 263 
Phase de grand mouvements, 491 
Phenyl-hydracin test for sugar in urine, 403 
Phlegmon of larynx, appearance of, 538 
Phloroglucin-vanillin reaction, 317 
Phonation, vibrations of glottis in, 133 
Phonendoscope, value of, 120 
Phosphate, deposit of, in urine, 363 

of lime in urine, 389 
Phosphatic calculi, 391 
Phosphaturia, 389 

Phosphorus-poisoning, cutaneous hemorrhage 
in, 46 

leucin and tyrosin in urine of, 390 

odor from mouth in, 253 

odor of vomit in, 332 

peptonuria with, 398 
Phrenic nerve, unilateral paralysis of, detected 

by palpation, 91 
Phthisical thorax, 76 
Phthisis, accommodation in, 85 

aspergillus fumigatus in sputum of, 150 

asymmetrical breathing in, 81 

diminished inspiratory pressure in, 141 

diminution of size of apex of lung in, 118 

ferment in sputum of, 164 

form of thorax in, 76 

friction-sounds in, 133 

lagging in, 91 

neuralgia in, 447 

night-sweats of, 34 

odor of sputum in, 147 

orthopnea in, 29 

sudden stopping of cough in, I42 

systolic subclavian murmur in, 222 

tenderness with, 90 

thoracic tenderness in, 90 

vital capacity of lungs in, 141 
Picric acid, color of urine after taking, 371 

test for albumin in urine, 395 
Pigeon-chest, 78 
Pill-maker hand, 489 
Pilocarpin, effect of, on pupil, 517 
Pio Foa's coccus in sputum, 162 
Piorry, reference to, as a reviver of percussion, 

92 
Plasmodium malariae, 247 
Plegaphonia, 135 
Pleura, diseases of, form of thorax in, 72 

exploratory puncture of, 136 

left, exudation in, dulness of halfmoon- 
shaped space in, 275 

thickened, sensation of resistance over, 102 

thickening of, diminished vesicular breath- 
ing in, 124 
percussion-deadness in, 112 

tumors of, weakness of vocal fremitus in, 

134 
Pleural cough, 142 

exudations, chemical examination of, 139 
determination of albumin in, 139 
diminished vesicular breathing in, 124 
examination of, for bacteria, 137 
hemorrhagic, 139 



Pleural exudations, microscopic examination 

of, 137 
sacs, boundaries of, 71 
sinus, complementary, 71 
Pleurisy, asymmetry of breathing in, 81 
carcinomatous, exudation in, 137 
diaphragmatic, tympanitic sound in, 112 
differential diagnosis from pericarditis and 

peritonitis, 200 
diminution of motility of lungs in, 118 

of spleen-dulness after, 301 
downward displacement of liver in, 289 
drawing-in of thorax from, 77 
dyspnea in, 85 

effect of, on position of liver, 295 
encapsulated, in 

exudative, non-tympanitic sound in, 89 
from fracture of rib, 90 
lagging in, 91 
leukocytosis in, 242 
position in bed in, 29 

streptococcus pyogenes in exudations of, 138 
Pleuritic exudation a cause of deadening of 
percussion resonance, 1 1 1 
anuria in, 367 

feculent ichorous, micro-organisms in, 138 
ichorous, micro-organisms of, 138 
increased vocal fremitus in, 134 
sensation of resistance over, 102 
weakness of vocal fremitus in, 134 
friction-sounds, 132, 200 
Pleuritis, adhesive, vein-nets on chest and 
back in, 225 
vital capacity of lungs in, 141 
diaphragmatica, detection of, by palpation, 

91 
exudative, bronchial breathing in, 126 
diminished inspiratory pressure in, 141 
displacement of apex-beat in, 173 
displacement of liver in, 291 
extension of liver-dulness in, 295 
tympanitic sound in, 98 
exploratory puncture in, 136 
Frankel's pneumococcus in, 163 
friction-sound in, 132 
pulse in, 218 
purulent, 90 

sicca a cause of friction sounds, 132 
staphylococcus pyogenes albus in the exu- 
dation of, 138 
tenderness of thorax in, 90 
with emphysema, friction-sounds in, 133 
Pleximeter, 92, 93 
Pneumatometry, 141 . 
Pneumatoscope of Gabritschewsky, 135 
Pneumococci, methods of staining, 163 
Pneumococcus, Frankel's, 162 
Friedlander's, 162 

in cerebrospinal fluid in epidemic cerebro- 
spinal meningitis, 435 
of Frankel in pleural exudations, 138 
Pneumonia, abnormally loud, deep percussion- 
sound in, 116 
absence of cough a bad sign in, 165 
asymmetry of breathing in, 81 
bloody sputum in, 145 
bronchial breathing in, 125 



INDEX, 



589 



Pneumonia, catarrhal, crepitant rales in, 13 

deadening of percussion-sound in, no 

thickening and deadening with, 1 10 
caused by dust, 21 
cocci in sputum, 162 
course of fever in, 61 
critical sweat in, 34 
croupous, bloody sputum in, 146 

bronchial breathing in, 126 

crepitant rales in, 131 

Curschmann's spirals in, 155 

deadened resonance over lungs in, 109 

feehng of resistance in, 109 

fever in, 59 

frequent respiration in, 84 

hemorrhage from lungs in, 146 

herpes facialis with, 145 

one-sided expansion of chest in, 76 

spiral casts in, 149 

tenderness with, 90 

tube-casts in, 149 

tympanitic sound in, 98, 1 13 
diminution of chlorids of urine in, 392 
dry cough in, 143 
dyspnea in, 85 
epileptiform convulsions in beginning of, 

.490. 

epithelium in sputum of, 151 

extended perception of heart-sounds in, 187 

Frankel's pneumococcus in sputum of, 162 

frequent pulse in, 205 

friction-sounds with, 133 

Friedlander's pneumococcus in, 163 

increase of urea in, 392 
of vocal fremitus in, 134 

lagging in, 91 

leukocytosis, 242 

lobular, thickening and deadening with, I lo 

massive, dulness in, 1 10 

sensation of resistance in, 102 

mucous threads in sputum of, 150 

non-tympanitic sound in, 99 

peptone in sputum of, 164 

peptonuria with, 398 

position in bed in, 29 

pulse in, 205 

ringing dry riles in, 129 

smallness of halfmoon-shaped space in, 276 

spirals in sputum of, 149, 150 

sudden stopping of cough in, 142 

tenderness of thorax in, 90 

vomiting in, 326 
Pneumonic deposits, cracked-pot sound in, 116 
Pneumonokoniosis, pleuritic friction-sounds, 

132 
Pneumopericardium, diminution of heart-dul- 
ness in, 182 

metallic heart-sounds in, 191 

metallic sound over, 99 

tympanitic sound in, 98 
Pneumothorax a cause of cyanosis, 39 

amphoric breathing in, 127 

bronchial breathing in, 126 

cracked-pot sound in, 116 

displacement of apex-beat in, 173 

downward displacement of liver in, 289 

dyspnea in, 85 



Pneumothorax, effect of, on position of liver, 

295 

expansion of chest in, 76 

liver-dulness in, 295 

loud, deep percussion-sound in, 117 

lung-sound over, 99 

metallic heart-sound in, 191 
rales, 131 
sound over, 98 

non-tympanitic sound over, 99 

one-sided expansion of lungs in, 117 

plegaphonic sound in, 135 

position in bed in, 29 

pulse in, 211 

relative liver-dulness in, 296 

tympanitic sound in, 98, 116 

weakeness of vocal fremitus in, 134 
Poikilocytes, 240 
Poikilocytosis, 241 
Points douloureux, 448 

of electrical stimulation, 469. See Motor 
points. 
Poisoning, acute, albuminuria in, 394 

disturbance of consciousness in, 437 
Poisons in urine, 41 1 
Poles of battery, how to distinguish, 466 
Polio-encephalitis, choreic motions in, 492 
Poliomyelitis, 454 

acute, arrest of growth of bones after, 530 
disunion of atrophy and paralysis in, 
456 

bladder disturbance absent in, 528 

decreased tendon reflexes in, 461 

epileptiform attacks in beginning of, 490 

reaction of degeneration in, 484 

vasomotor disturbances in, 526 
Pollution from irritation of penis, 529 
Polydipsia, polyuria from, 367 
Polyesthesia, 443 
Polypi, nasal, relation of, to nervous diseases, 

525 
Polyuria, 366 

in nervous disease, 528 

nervous, 367 
Pons Varolii, symptom of disease of, 425 
Portal vein, obstruction of, ascites in, 282 

occlusion of, enlargement of spleen in, 
298 
Position of patient, 28 

passive dorsal, 28 
Positions, compulsory, 30 
Posner on albumin in urine in health, 366 
Post-epicritical increase of urea in pneumonia, 
392 

-epileptic coma, 490 
Postponing intermittent fever, 63 
Posterior rhinoscopy, 544 
Posticus paralysis, 542 
Posture of patient, 28 

Pregnancy, double sound over crural artery in, 
222 

scars of, 46 
Pressing noise, 268 
Pressure-sense, testing of, 440 
Presystolic heart- murmur, 194 
Primary deviation, 515 

myopathic atrophy, 455 



590 



INDEX. 



Profession as a factor in causation of disease, 

21 

Progressive muscular atrophy, 454 
cyanosis in, 39 
fibrillary contractions in, 490 
paralysis, diminution of temperature in, 525 

fever in, 525 

light rigidity of pupil in, 518 

perforating disease of foot in, 530 
Propepsin, secretion of, 321 

by stomachj 305 
Propeptone, test for, 322 

Prostate, hypertrophy of, residual urine in, 368 
Prostatitis, prostatorrhea in, 413 
Prostatorrhea, 413 
Prune-juice sputum, 145 
Prussic-acid poisoning, glycosuria in, 401 

odor from mouth in, 253 
Pseudo-crisis, 61 
Pseudobulbar paralysis, speech-disturbance 

rare in, 502 
Pseudohypertrophy, 456 
Pseudoleukemia, ascending venous pulse in, 

229 
Pseudoparalysis, spastic, 456 
Pseudo-vacuoles, 249 
Psoas, paralysis of, effect of, 500 
Psychoses, increased secretion of saliva in, 

.527 
Ptomains, connection between, and cystin in 

urine, 390 
Ptosis from paralysis of oculomotorius, 515 
Ptyalism, 256 
Puerile breathing, 122 

origin of, 122 
Puerperal fever, peptonuria with, 398 
temperature in, 57 
pyemia, streptococcus pyogenes in, 549 
Pulmonary artery, aneuiysm of, 219 
heart-sound, strengthened, 188 
stenosis, effect of, 168 
Pulsating tumor of spleen, 298 
Pulsation, epigastric, 177, 272 
Pulse, 201 

anomalies of, in nervous disease, 526 

as an indication of strength of heart, 21 8 

auscultation of, 221 

bulbar, 227 

capillary, 220 

-curve in health, 212 

pathological, 213 
daily variations in, 20I 
diagnostic value of, 216 
dicrotic, 213 
empty, 208 
equal, 203 

examination of, diagnostic value of, 216 
filiform, 209 

frequent, occurrence of, 204 
full, 208 
hard, 210 
hardness of, 210 

influence of deep breathing upon, 202 
of external temperature upon, 202 
of meals on, 202 
of mental excitement upon, 202 
of movement on, 202 



Pulse, influence of position of body on, 202 

of sex on, 201 

of size of body on, 201 

of sleep upon, 202 
irregular, 209 
large, 208 
liver-, 221 

method of observing, 202 
monocrotic, 213 
normal, 201 

frequency of, 201 
palpation of, 201 
pathological frequency of, 203 
quality of, 203, 208 
quick, 209 
radial, examination of, 201 

in pericarditis, 174 
regular, 209 
retardation of, 203 
rhythm of, 202 
slow, 209 
small, 208 

sphygmography of, 21 1 
subdicrotic, 213 
superdicrotic, 213 
suspended, 207 
symmetry of radial, 210 
tense, 210 
thread-like, 209 
trembling, 209 
vpnous, 226 
want of rhythm of, 207 
wire, 210 
Pulsus aequalis, 209 
alterans, 209 
bigeminus, 203 

tracing of, 215 
celer, 209 

sphygmographic curv^e of, 214 
deficiens, 207 
dicrotus, 209 
diflerens, tracing of, 215 
durus, 210 
iucequalis, 209 
intercidens, 208, 209 
intermittens, 203, 207 
magnus, 208, 209 
mollis, 210 
paradoxus, 209 
parvus, 208 
plenus, 208 
rarus, 203 
tardus, 209 

tracing of, 214 
tensus, 210 
tremulus, 209 
trigeminus, 207 

alterans, 203 
vacuus, 208, 210 
Punctiform ecchymoses in epilepsy, 529 
Puncture, exploratory, of heart, 200 

of liver,292 
lumbar, 434 

of abdomen, to draw off ascitic fluid, 285 
of peritoneal cavity, diagnostic value of, 285 
of pleura, exploratory, 136 
Pupil, contracted, 517 



INDEX. 



591 



Pupil, dilatation of, 517 

from paralysis of oculomotorius, 515 
effect of poisons on, 517 
inequality of, 517 
light reflex of, 518 
light rigidity of, 518 
reflex changes in size of, 517 
rigid, 518 

rigidity of, as a symptom, 533 
size of, 517 
Purpura haemorrhagica, cutaneous hemor- 
rhage, 46 
Purulent exudations in sputum, 143 
pleuritis, 90 
sputum, 145 
stools, 339 
Pus-cocci in urine, 385 

-corpuscles in urine, 377, 378 

in cerebrospinal fluid, 435 

in larynx, 539 

in stomach-contents, 315 

in stools, 339 

in urine, 377 

makes it turbid, 371 
odor of urine in, 373 
reaction of urine with, 373 
vomiting of, 330 
Putrefaction of stomach-contents, 309 
Pyelitis, bacterium coli commune in, 383 
calculosa, thickening and distention of 

ureters in, 360 
cylindroids in urine of, 375 
white blood-corpuscles and pus in urine of, 

377 
Pyelonephritis, peculiar hyaline casts in urine 

of, 381 
Pyemia, cutaneous hemorrhage in, 46 

enlargement of spleen in, 298 

frequent pulse in, 205 

herpes in, 45 

intermittent fever in, 63 

pulse in, 205 

pus-cocci in urine in, 385 

retinal hemorrhage in, 548 

staphylococcus pyogenes in, 548 

streptococcus pyogenes in, 549 

sweat in, 34 
Pyemic deposits in lungs, friction-sounds in, 

endocarditis, retinal hemorrhage in, 548 
Pyloric stenosis. See Stenosis of pylorus. 
Pylorus, congenital displacement of, 271 
position of, 268 
spasm of, 310 

stenosis of, effects of, on digestion, 310 
Pyonephrosis, palpation of, 358 
Pyopneumocardium, metallic pericardial 

splashing in, 200 
Pyopneumothorax, change of boundaries of 
dulness in, 112 
metallic sound in, 117 
splashing sound in, 133 
subphrenicus, 284 
Pyramidal tract, 416 

above oblongata, affections of, speech- 
disturbance in, 502 
effect of lesion of, 425 



Pyramidal tract, lateral, 417 
Pyrocatechin, effect of, in urine, 371 
Pyrosis hydrochlorica, superacidity in, 325 
Pyuria, 377 

due to strongylus gigas, 382 

Quadriceps muscles, paralysis of, effect cf, 
500 

Qualitative irritability of muscles from gal- 
vanic stimulation, 478 

Quantitative excitability of nerves and mus- 
cles, 476 

Quartan intermittent fever, 63 

Quincke on fever from injury of cervical 
spinal cord, 525 
on progressive venous pulse, 229 
on proportion between urine secreted dur- 
ing day and that secreted at night, 
362 
pseudo-vacuoles, 249 

Quincke's lumbar puncture, 434 

Quinia in urine, 41 1 

Quotidian intermittent fever, 63 

Rachitic chest, 78 

Rachitis as a cause of chest deformity, 79 
diminution of phosphates in urine in, 392 
enlargement of cranium in, 430 
how distinguished from hydrocephalus, 431 
Radial artery, abnormal course of, 208 

nerve, cutaneous filaments of, supplying 
dorsal side of arm, 449 
electric stimulation of, 472 
muscles supplied by, electrical examina- 
tion of, 475 
paralysis of, 451 
pulse. See Pulse. 
asymmetry of, 245 
Radomyski, casts in urine in disturbance of 

circulation, 380 
Rales, bubbling, 13 1 
consonant, 130 
crepitant, 131 
dry, 128 
" hinted," 130 
metallic, 128 
moist, 129 
palpation of, 89 
ringing, 130 
sibilant, 128 
viscid-moist, 129 
Raspberry -jelly sputum, 141 
Reaction of degeneration, 478 
as a symptom, 531 
complete and partial, 479 
course of, 480 
mechanical, 485 
mixed, 484 

partial, significance of, 484 
relation of, to course of paralysis, 481 
schematic representation of, 479 
significance of, 484 
varieties of, 483 
when absent, 484 
when occurs, 484 
of expectoration, 144 
of Koch's tuberculin, 1 65 



592 



INDEX. 



Recoil-elevation of pulse-curve, 212 
Records of cases, value of, 24 
Rectum, palpation of, 280 

stenosis of, pain at stools in, 335 
tumors of, examination of, 279 
Rectus externus of eye, paralysis of, 515 
inferior, paralysis of, effect of, 515 
internus, paralysis of, effect of, 515 
superior, paralysis of, effect of, 515 
Recurrent fever, 64 

spirillum recurrens in blood of, 246 
paralysis, 542 
Red blood-corpuscles. See Blood- corpuscles. 

in sputum, 15 1 
Redness of larynx, when occurs, 538 

of skin, abnormal, 37 
Reducing substances in urine in health, 366 
Reflex centers, 419 
cremaster, 458 
of sole of foot, 457 
patellar, 459 
rigid pupil, 518 
skin, testing of, 457 
tendo-Achillis, 460 
Reflexes, 457 
abdominal, 458 
fascial, 460 

of mucous membranes, 458 
periosteal, 460 
skin, 457 
tendon, 458 
Reiss on strong percussion to determine size 

of heart, 179 
Relapsing fever, 64 
Relative deadness of sound, 95, 96 
Remittent fever in the course of febrile dis- 
eases, 61 
range of temperature in, 56 
vomitmg in, 326 
Renal albuminuria, when occurs, 394 
calculi, fever in, 57 
casts, additions to, 381 

kinds of, 380 
colic, 391 

engorgement, hyaline casts in urine of, 380 
epithelium in urine, 379 
Rennet ferment, secretion of, 306 

zymogen in gastric juice, determination of, 
321 
Residence, place of, as a factor in cause of 

■ disease, 21 
Residual urine, 368 

Resistance of skin to electrical conduction, 
determination of, 474 
sensation of, 102 
Resonance, deadened, over the lungs, 109 

when deadened, 109, 1 12 
Resorcin as a test for hydrochloric acid in 
stomach, 317 
in urine, 411 
Resorption of exudation or fluid of edema, 
polyuria from, 366 
of food, 335 
Respiration, anomalies of, 79 
Riot's, 83 
Cheyne-Stokes, 81 
examination of movements of thorax in, 91 



Respiration in diseases of nose, 66 
increased and forced, 86 
normal, 72 

auscultatory signs in, 121 
rapidity of, 73 
Respiratory apparatus, disturbances of, in 
nervous disease, 525 
change of acme of sound, 115 
motions, effect on circulation in jugular 

veins, 225 
sound, change of, 99 
sounds, pathological, 123 
Retentio urinae, 528 

Retinal apoplexy a forerunner of cerebral 
hemorrhage, 547 
arteries, pulsations of, 548 
hemorrhages, 547, 548 

in general hemorrhagic diathesis, 514 
Retinitis albuminurica, 547 
pigmentosa from syphilis, 547 
syphilitica, 547 
Retroperitoneal glands, enlargement of, 303 

confounded with aortic aneurysm, 303 
Retropharyngeal abscess a cause of cyanosis, 

38 
detection of, 260 
Reuss' formula for determination of albumin, 

139 
Reynolds on test for acetone in urine, 409 
Rhagades, significance of, 253 
Rheostat, importance of, 462 
Rheumatic facial paralysis, disturbance of 
hearing with, 523 

paralyses, reaction of degeneration in, 484 
Rheumatism, articular, entrance of, through 
tonsils, 258 
perspiration in, 34 

chronic articular, phosphaturia in, 389 
pain in spine in, 447 

of chest-muscles, pain of, 90 

of thorax, frequent respiration in, 84 

peptonuria with, 398 
Rhinoscopy, 543 

anterior, 543 

posterior, 544 
Rhomboideus, paralysis of, effect of, 497 
Rhubarb, color of urine after taking, 371 
Ribs, caries of, as a cause of pleurisy, 90 

fractures of, diagnosis of, 90 
increased respiration in, 84 

pain in disease of, 90 
Rice-water stools, 338 
Richardson's sphygmograph, 21 1 
Riegel's double stethograph, 141 
Rigidity of muscles, 456 
Ringing rale, 130 
Risus sardonicus, 490 
Robertson's pupil, 518 
Rod-pleximeter percussion, 1 17 
Rolando, fissure of, location of, 432 
Rolando's line, 432 
Romberg's symptom, 445 
Rosenbach's modification of Gmelin's test for 

bile-pigments, 400 
Rosenstein on absence of free hydrochloric 

acid from stomach in diabetes, 324 
Roseola, 44 



INDEX. 



593 



Roseola syphilitica, 44 

Rosin's test for bile-pigments in urine, 401 

Rossler, experiments with Esbach's albu- 

minometer. 398 
Round worms, 343 

in vomit, 331 
Rubor pudicitise, 37 
Rumpf on signification of Wintrich's change 

of sound, 114, 115 

Saccharomyces in urine, 385 
Sahli on cyanosis in Cheyne-Stokes respira- 
tion, 82 
on origin of puerile breathing, 122 
Sahli's improvements of Penzoldt's test, 

323 
theory of anemic murmurs, 197 
Salicylic acid in urine, test for, 410 
Saliva, diminution of, 256 
examination of, 256 
increased secretion of, 256 

in nervous diseases, 527 
of nephritis, urea in, 256 
Salivary glands, examination of, 256 
Salivation, 256 

Salkowski-Leube method of quantitative test- 
ing for sugar in urine, 404 
Salkowski on composition of Charcot- Leyden's 

crystals, 157 
Salol in urine, 41 1 

method of Ewald for determining rapidity 
with which stomach empties its con- 
tents into duodenum, 322 
Salter on displacement of lower border of 

lungs in lying down, 109 
Sanger, palpation of ureters through vagina, 

359 
Santonin, color of urine after taking, 371 
Sarcina pulmonalis in sputum, 159 

ventriculi in vomit, 331 
Sarcinae in stomach- contents, 316 

in urine, 385 
Sarcoma of kidney, palpation of, 358 
of larynx, 541 

of skull, projections caused by, 431 
Satyriasis, 439 
Scanning speech, 502 
Scaphoid drawing-in of abdomen, 279 
Scarlet fever, condition of tonsils in, 259 
cutaneous hemorrhage in, 46 
enlargement of spleen in, 298 
entrance of, through tonsils, 257 
epileptiform convulsions in beginning of, 

490 
glycosuria in, 402 
hemoglobinuria in, 370 
mulberry-tongue in, 254 
vomiting in, 326 
Scars, 46 

Scherwald's plegaphonia, 135 
Schizomycetes in stomach-contents, 316 
Schmidt discovered Curschmann's spirals in 
upper lobes of asthma-patients, 155 
on Curschmann's spirals in hardened 
sputum, 155 
Schmiedeberg's method of quantitative testing 
for sugar in urine, 405 

38 



Schultze on reaction of degeneration in myo- 
pathic muscular atrophy, 483 
Sclerosis, amyotrophic lateral, 454 

diminished electric irritability in, 485 
increased tendon-reflexes in, 461 
reaction of degeneration in, 484 
arterial, "goose's throat" in, 220 
multiple, allochiria in, 443 
atrophy of optic nerve in, 513 
concentric narrowing of field of vision 

in, 521 
imbecility from, 438 
intention tremor in, 489 
narrowing of field of vision in, 521 
nystagmus in, 516 

primary atrophy of optic nerve in, 547 
vertigo in, 438 
of aorta, shown by stronger aortic second 

sound, 188 
of arteries a cause of hypertrophy of left 
ventricle, 120 
Scoliosis, 78 

Scorbutus, cutaneous hemorrhage in, 46 
hematuria in, 376 
loosening of teeth in, 253 
peptonuria with, 398 
Scotoma, central, when occurs, 521 
Scurvy, oxybutyric acid in urine, 408 
Scybala, recognition of, 279 
Secondary deviation, 515 
Sediments in urine, -^^2)^ 3^5 

pathological, 374 
Sedimentator, Stenbeck's, 374 
Sehrwald, method of determining urea of 

urine, 392 
Seitz, metamorphosing breathing, 127 
Self-registering thermometer, advantages of, 

Semi-decussation of optic tract, 420 
Seminal fluid, examination of, 411 
Senator on albumin in healthy urine, 366 

on ascending venous pulse in pseudoleu- 
kemia and leukemia, 229 

on leukocytes in urine, 378 

on origin of epithelium in sputum, 151 
Senna, color of urine after taking, 371 
Sensation of movements, testing of, 440 

of resistance, 102 

of spasm, testing of, 444 
Sense of heat and cold, testing of, 440 

of pressure, testing of, 440 

of space, testing of, 440 

of touch, testing of, 439 

organs, 513 
Sensibility, cutaneous, 439 

delayed, 443 

disturbances of, 439 

double, 443 

to pain, testing of, 441 
Sensitive tracts, 419 
Sensory aphasia, 506 
Sepsis, enlargement of spleen in, 298 

retinal hemorrhage in, 514 
Seropneumothorax, change of boundaries of 
deadness in, 112 

metallic sound in, 1 17 

splashing in, 133 



594 



INDEX. 



Serous sputum, 145 

Serratus muscle, paralysis of, effect of, 497 
Serum-reaction in typhoid fever, 247 
Shaking-spasm, 489 
Sharpness of vision, testing of, 519 
Shoemakers' breast, 79 
Shreds of tissue in urine, 379 
Sibilant rales, 128 
Sibeon's furrow, 69 
Siegel's pneumatic ear-speculum, 546 
Sieveking's esthesiometer, use of, 440 
Sight, center and tract for, 420 
Silver in urine, 411 

Simon, palpation of ureter through the rec- 
tum, 359 
Singing, loss of power of, in atactic aphasia, 

508 
Singultus, 496 
Sinus head, 342 

phrenico-costalis, 71 
Situs viscerum inversus, 167 
Sjoqvist's method of determining free plus 
loosely-combined hydrochloric acid 
in stomach, 319 
Skeleton, defective development of, 30 
Skin, abnormal redness of, 37 

appearance of, in ascites, 282 

blue-red, ■},% 

bronze, 43 

color of, 34 

disturbances of, relation to nervous dis- 
orders, 529 

edema of, 46 

emphysema of, 49 

gray, from silver deposit, 44 

hemorrhages in, 45 

moisture of, 32 

nutrition of, 32 

pale, 35 

-reflexes, 457 

mechanism of, 458 

state of nutrition of, 32 
Skoda, influence on development of ausculta- 
tion, 119 

on percussion-sounds, 96 

recoil-theory of apex-beat, 172 

reference to, as reviver of percussion, 92 
Skull, asymmetry of, 431 

examination of, 430 

form of, 431 

projections and depressions on, 431 
Sleep-paralysis, effect of, 498 
Small-pox, cutaneous hemorrhage in, 46 

enlargement of spleen in, 298 

laryngitis in, 68 

vomiting in, 326 
Smell, loss of sense of, 524 

testing of, 523 

tract of, 421 
Snellen's plate, 519 
Soft palate, electric stimulation of, 471 
innervation of, 494 
paralysis of, 494 
Solidification of lungs, percussion-sound in, 

loi 
Sommerbrodt's sphygmograph, 21 1 
Somnolence, definition of, 437 



Sopor, definition of, 437 
Sound-image center, location of, 505 

metaUic, 98 

use of, in examining nasal cavities, 544 
Sounding of the esophagus, 264 

of stomach, 272 
Sounds of falling drops, 131 

percussion, 94 
Space-sense, testing of, 440, 445 
Spasm of chest-muscles, dyspnea in, 85 

of glottis a cause of cyanosis, 38 

of muscles of larynx, 541 

of respiratory muscles a cause of cyanosis, 

39 
-sense, testing of, 444 
shaking-, 489 
Spasms, clonic, 488 
when occur, 490 
co-ordinated, 491 
dissociated, 490 
kinds of, 489 
of voluntary muscles, 488 
tonic, 488 

when occur, 490 
Spastic paralyses, 419 
pseudoparalysis, 456 

spinal paralysis, increase of tendon-reflexes 
in, 461 
Specific gravity of urine, 363 

in disease, 372 
Speech-center, location of, 505 
motor, location of, 505 
disturbances of, 502 
how acquired, 503 
scanning, 502 
Sperma-ci-ystals in semen, demonstration of, 

412 
Spermatic fluid, abnormal, 412 

normal, 411 
Spermatorrhea, 414 
Spermatozoa in urine, 379 
Sphygmograph, pathological forms of pulse 

shown by, 212, 213 
Sphygmography, 211 
Sphygmomanometer, 210 
Spinal column, diminished mobility of, 434 
form of, 434 

sensitiveness to pressure, 434 
cord diseases, localization of, 427 
feeling of constriction in, 446 
topographical diagnosis of, 423 
relation of, to spinal column, 434 
disease, aspermatism from, 412 

spermatorrhea in, 414 
irritation, pain in spine in, 447 

sensitiveness to pressure in, 434 
paralysis. See Paralysis. 
Spirals, Curschmann's, 154 

in expectoration of bronchial asthma and 

croupous pneumonia, 149 
in sputum, 154 
Spirillum recurrens in blood, 246 

in urine, 385 
Spirometry, 141 
Spleen, anatomy of, 296 
auscultation of, 302 
consistence of, 298 



INDEX. 



595 



Spleen, displacement of, 299 

-dulness, 299 

diminution of, 301 
enlargement of, 301 
size of, 300 

enlargement of, diagnosis of, 301, 302 
expansion of thorax in, 77 
from general venous engorgement, 224 
projection of left hypochondrium in, 

297 
smallness of Traube's space in, 275 

examination of, 296 

form and surface of, 298 

inspection of, 297 

-lung angle, 297 

mobility of, 299 

palpation of, 297 

pathological relations of, 301 

percussion of, 299 

peritoneal friction-sounds heard over, 302 

relation to colon, 299 

size of, 298 

systolic pulsation of, 298 

tenderness of, diseases in which it occurs, 
298 

tumors of, 298 

wandering, 298, 299 

when it can be felt, 298 
Spontaneous pain, 446 
Sputa, confluent, 145 
Sputum, 143 

actinomyces in, 164 

albuminous corpuscles in, 164 

animal parasites in, 157 

aspergillus in, 164 

bile-pigment in, 147 

bloody, 145 

cartilage in, 148 

cercomonas in, 158 

Charcot-Leyden's crystals in, 156 

chemical examination of, 164 

cholesterin-crystals in, 156 

coal-soot in, 147 

crystals in, 149, 155 

crystals of fatty acid in, 156 

distoma pulmonale in, 158 

echinococcus in, 157 

elastic fibers in, 152 

epithelial cells in, 151 

ferment in, 164 

fibrinous tubes in, 148 

foreign substances in, 147 

Frankel's pneumococcus in, 162 

Friedlander's pneumococcus in, 162 

fungi in, 149, 158 

green, 147 

heart-disease cells in, 151 

hematoidin in, 147 

infusoria in, 158 

iron-dust in, 147 

leptothrix buccalis in, 158 

lung-tissue in, 147 

microscopical examination of, 1 50 
method of, 153 

monas in, 158 

mould in, 164 

mucopurulent, 145 



Sputum, mucous corpuscles in, 150 
mucus in, 144 
odor of, 147 
oxalate of lime in, 157 
peptone in, 164 
Pio Foa's coccus in, 162 
pneumonia cocci in, 162 
prune-juice, 145 
purulent, 145 

red blood-corpuscles in, 151 
sarcina pulmonalis in, 159 
serous, 145 

starch-corpuscles in, 155 
threads of muscles in, 150 
triple phosphate in, 157 
tubercle bacillus in, 159 
tyrosin in, 157 

white blood-corpuscles in, 150 
Square position of liver, 295 
Squibb's modifications of urinometer, 364 
Squirting noise, 268 

Stadelmann on ferment in sputum of phthisis, 
164 
on formation of bile-pigment in poisoning, 

41,42 
on oxybutyric acid a cause of diabetic 

coma, 407, 408 
on peptone in sputum, 164 
Stagnation of stomach -contents, 309 
Staphylococcus pyogenes albus, 548 

in exudation of empyema, 138 
in pleural exudates, 138 
aureus, 548 

in exudations of empyema, 138 
cereus, 548 
citreus, 548 

in exudations of empyema, 138 
importance of, 548 
Starch-corpuscles in sputum, 155 

-grains in vomit, 331 
Starches, digestive changes in, 304 
Stenbeck's sedimentator, 374 
Stenosis, aortic, effect of, 168 
pulse in, 217 

-curve in, 214 
pulsus tardus in, 210 
systolic heart-murmur over carotid in, 
222 
arterial, pulsus tardus in, 210 
intestinal, distention of abdomen in, 278 
laryngeal, distinguished from tracheal sten- 
osis, 67 
mitral, arrhythm in, 207 
diastolic murmur in, 193 
division of second apex-sound in, 190 
effect of, 168 
irregular pulse in, 209 
pulse-curve in, 215 
pulse in, 216 
small pulse in, 209 
strengthening of apex-sound in, 188 
of air-passages, diminished vesicular breath- 
ing in, 124 
breathing in, 81 
of aorta, commencement of absence of 
apex-beat in, 175 
systolic murmur in, 193 



596 



INDEX. 



Stenosis of bronchi, inspiratory drawing-in 
of, 87 
of esophagus, symptoms of, 263 
of heart-openings, murmurs in, 191 
of intestine, obstipation in, 334 

visible peristalsis in, 279 
of larynx, inspiratory drawing-in of, 87 
of pylorus, carcinomatous, effect on diges- 
tion, 310 
effect on digestion, 310 
hypacidity in, 324 
of rectum, pain at stools in, 335 
of trachea, inspiratory drawing-in of, 87 
of valve, 168 

ostii aortse, retardation of pulse in, 204 
pulmonary, systolic murmur in, 193 

effect of, 168 
pyloric, anacidity of stomach in, 325 
diminished volume of abdomen in, 278 
food in stomach after digestion of test- 
breakfast, 323 
tricuspid, diastolic murmur in, 193 
effect of, 168 

venous' engorgement in, 224 
Stereognosis, 446 
Sterility, 21 
Sternal lines, 69 

Sternum, percussion-sound over, 106 
Stethography, 141 

Stethoscope, varieties and use of, 1 19 
Stiffness of joint, diminution of power of 

motion from, 452 
Stigmates hysteriques, 491 

as a symptom, 533 
Stintzing on quantitative excitability of nerves 
and muscles, 476-478 
on reaction of degeneration, 483 
Stokes on Cheyne-Stokes respiration in fatty 
degeneration of heart, 82 
on vesicular murmur louder on left side 
than on right, 122 
Stolnikow on ferment in sputum, 164 
Stomach, absorption by, 307 
anacidity of, 309 
anatomy of, 268 
antiperistalsis of, 272 
artificial distention of, 271 

emptying of, 303 
artificially dilated, percussion of, 274 
auscultation of, 276 
boundary illustrated, 274 
cancer of, tumors in, 273 
catarrh of, stomach-contents in, 31 1 
-colon fistula, diagnosis of, 280 
-contents, abstraction of, for examination, 312 
examination of, 303, 315 
by microscope, 316 
by the eye, 315 
chemical, 316 
fermentation of, 309 
gases in, 310 
putrefaction of, 309 
removal of, for examination, 303 
stagnation of, 309 
-cough, 142 
diaphanoscopy of, 276 
-digestion described, 304 



Stomach-digestion, duration of, 305 

of nurslings, 308 

results of examination of, 323 
dilatation of, from pyloric stenosis, vomiting 

in, 327 
-disease, coating of tongue in, 255 

vertigo from, 438 
distensibility of, 271 
distention of, 271 
ectatic dilatation of, 310 
examination of, 268 

during digestion, 277 
-gases, determination of, 314 
greater curvature of, 269 
-heart space, 275 

hour-glass, recognition of, by inflation, 272 
how soon it empties its contents into duod- 
enum, 322 
hypacidity of, 308 
hyperacidity of, 309 

hypertrophy of, peristaltic motions in, 272 
illumination of, 276 

increased resistance of, on palpation, 272 
inflated, metallic heart-sounds in, 191 
inflation of, for diagnosis, 271 
inspection of, 270 

length of time that food remains in, 31 1 
lesser curvature of, 269 
-liver space, circular, 275 
location of, 268 
-lung space, circular, 275 
metallic sound over, 98 
motor activity of, diminution of, 309 
non-tympanitic sound over, 99 
palpation of, 270 

by striking, 272 
percussion of, 273 

with rod-pleximeter, 275 
peristaltic motions in, 272 
peristaltic unrest of, 272 
-sound, contraindications to use of, 312 

introduction of, 313 
after test-meal, 315 
sounding of, 272 
-splashing, 276 
subacidity of, 308 
superacidity of, 309 
tenderness of, to palpation, 273 
-tubes, 313 

tumors of, dulness on percussion, 275 
tympanitic sound over, 98 
washing out of, 312 
Stomatitis, bacteria of mouth increased in, 

257 
enlargement of tongue in, 254 
Stone in bladder, hematuria in, 376 

in kidney, diminished secretion of urine in, 
368 
tenderness with, 357 
Stools, additions to, from alimentary canal, 
348 
admixtures of, 336 
amount of, 335 
bilious, 337 
bloody, 338 
color of, 336 
constituents of, 336 



INDEX. 



597 



Stools, consistence or form of, 336 

fatty, 338 

foreign bodies in, 337 

mucous, 337 

odor of, 336 

pain with, 335 

purulent, 339 

reaction of, 336 

rice-water, 338 

watery, 338 
Strabismus, 514 

convergent, 514 

divergent, 514 
Strangulation of intestine, obstipation in, 

334 
Strangury from concentration of urine, 361 
Streptococcus erysipelatis, 549 
pyogenes, 549 

in exudations of empyema, 138 
in pleural exudations, 138 
Stricture, aspermatism from, 412 

of esophagus, location of, by sounding, 266 
of urethra, diminished quantity of urine in, 
368 
residual urine, 368 
Stridor laryngeus, 67 
vel trachealis, 87 
Strongylus gigas causes pyuria and hematuria, 

382 
Structure of the body, 30 
Struma, murmurs over thyroid glands in, 223 
Striimpell on associated movements in spastic 
spinal paralysis, 492 
on choreic motions in polioencephalitis, 492 
on uremia, 399 

perverse sensibility to changes of tempera- 
ture, 443 
Strychnia in urine, 411- 

-poisoning, increase of tendon-reflexes in, 
461 
Stupor, 437 

Subacidity of stomach, 308 
Subclavian artery, auscultation of, 221 

left, compression of, pulsus dififerens in, 

215 
Subdicrotic pulse, 213 
Subjective sensations of vision, 522 

sensibility of hearing, 523 
Subphrenic abscess, 284 

downward displacement of liver in, 289 
Subscapularis, paralysis of, effect of, 498 
Succussion, Hippocratic, 133 
Sudamina, 45 

Sugar, absorption of, by stomach, 307 
in cerebrospinal fluid, 435 
in urine, approximate determination of, 406 
determination of, by circumpolarization, 

406 
in health, 366 
qualitative tests for, 402 
quantitative tests for, 404 
Sulphuretted hydrogen in urine, 373 
Sulphuric acid in urine, 392 

poisoning, glycosuria with, 401 
Superacidity of stomach, 309 
Superdicrotic pulse, 213 
Supinator longus, electric stimulation of, 471 



Suppuration, fever in, 57 
Supraclavicular depressions in emphysema of 
lung, 75 
percussion of, 104 
point, 471 
Supra-orbital nerve, distribution of, 448 
Suprascapular space, 69 
Supraspinatus muscle, function of, 497 
Suspended pulse, 207 
Swallowing, normal sounds of, 268 
Sweating, local, 34 
Swelling of larynx, when occurs, 538 
Syllable-stumbling, 507 
Sylvian line, 432 

Sylvius, fissure of, location of, 432 
Symptoms of diseases of brain and spinal cord, 

423 
Syncope, 438 
Syphihs as a cause of nervous disease, 529 

azoospermia in, 413 

changes in eye in, 547 

congenital, Hutchinson's teeth in, 253 

enlargement of liver in, 289 

hemoglobinuria in, 370 

hereditary, lips in, 253 

laryngitis in, 68 

mucous membrane of mouth in, 255 

neuralgia in, 447 

nocturnal headaches in, 447 

of central nervous system, light rigidity of 
pupil in, 518 

scars on larynx from, 540 

secondary, palate and tonsils in, 258 

tertiary, palate and tonsils in, 258 
tongue in, 255 

ulceration of larynx in, 539 
Syphihtic infiltration of larynx, 540 

ulceration of larynx, 539 
Syringomyelia, deforming arthritis in, 531 
Syringomyelitis, trophic disturbances of bones 

in, 53« 
ulcerations in, 530 
System-disease, 532 
Systole, movement of blood in, 108 
Systolia alterans, 175 

Systolic drawing-in near apex of heart, 175 
of intercostal spaces, 177 
pulsation in epigastrium, 177 

of spleen, 298 
trembling in epigastrium, 177 

Tabes, allochiria in, 443 
ataxia in, 488 
atonic paralysis in, 457 
bladder crises in, 528 

disturbances in, 528 
brittleness of bones in, 530 
cystitis in, 528 

decline of genital function in, 529 
delayed sensibility in, 443 
dorsalis, atrophy of optic nerve in, 513 

decreased tendon-reflexes in, 461 

myosis in, 517 

neuralgic, lightning-like pains in, 447 

Romberg's symptom in, 445 
feeling of constriction in, 446 
gastric crises in, 527 



598 



INDEX. 



Tabes, herpes zoster in, 529 
inequality of pupils in, 517 
intestinal crises in, 527 
light rigidity of pupil in, 518 
migraine in, 447 
mydriasis in, 517 
pain in spine in, 447 
partial paralysis of pressure-sense in, 440 
perforating disease of foot in, 530 
primary atrophy of optic nerve in, 547 
rectal crises in, 527 
residual urine in, 368 
sensitiveness of spine to pressure in, 434 
spermatorrhea, 414 
Tachycardia, 203 
occurrence of, 204 
paroxsymal, 207 
Tachycardic fit, 207 
Taenia cucumerina, 343 
mediocanellata, 342 
saginata, 342 
solium described, 341 
eggs of, described, 341 
Talma and Baas, explanation of moist rales, 

129 
Tape-worm, 341 
Taste, loss of sense of, 524 
testing of, 524 
tract of, 421 
Teale's case of high fever, 55 
Teeth, caries of, in diabetes mellitus, 253 
diseased, a cause of dyspepsia, 253 
eruption of, a cause of disturbance, 254 
examination of, 253 
first, eruption of, a cause of disturbance in 

infants, 254 
Hutchinson, 253 
loosening of, 253 
Temperature, daily variations of, 53 
diagnostic value of, 57 
elevated, 54 

exacerbation of, in fever, 56 
febrile, difference of, from normal, 55 
highest recorded, 55 
local elevation of, 65 
local lowering of, 65 
lowest observed, 56 
methods of taking, 50 
of the body, 50 

normal, 53 
perverse sensibilitity to, 443 
remission of, 56 
-sense, testing of, 440 
subnormal, 56 
Wunderlich's table of, 55 
Tenderness in region of stomach, 273 
of liver, 290 
over kidneys, 357 
Tendo-Achillis reflex, 460 
Tendon-reflexes, 458 
mechanism of, 461 
Tenesmus, 335 

of bladder, 361 
Tensor of vocal cords, paralysis of, 543 
Tensor tympani, predominant development of, 

disturbance of hearing in, 523 
Teres minor, function of, 498 



Tertian intermittent fever, 63 
Test-meal, 308 

composition of, 31 1 

Ewald's, 311 

Fleiner's, 312 

Kussmaul's, 312 

of Leube, 312 

of meat and starches, 312 

use of, 311 
Tetanus, cyanosis in, 39 

facial phenomenon in, 485 

fever in, 525 

increase of tendon-reflexes in, 461 

increased irritability in, 485 

mechanical excitability of nerves in, 485 

opisthotonos in, 434 

tonic spasms in, 490 
Thallin in urine, test for, 41 1 
Thermesthesiometer, 441 
Thermometers, methods of using, 51 

scale of, 51 

selection of, 51 
Thermometric scales, comparison of, 55 
Thermopalpation, 92 
Thigh-sound, 94 

when heard, 99 
Thoma-Zeiss counting-apparatus, 238 
Thomsen's disease, 456 
Thoracic muscles, paralysis of, 496 
spasms of, 496 

tonic and clonic spasms of, 496 
Thorax, deformity of, a cause of displace- 
ment of apex-beat, 172 

drawing-in or shrinking of one side of, 77 

emphysematous, 75 

form of, importance of, 30 

inflated, 75 

inspection of, 72 

local expansions of, 77 

measuring of, 140 

normal form of, 72 

one-sided expansion of, 76 

pain caused by pressure on, 88 

palpation of, 89 

paralytic, 76 

pathological forms of, 75 

percussion of, 92, 103 

phthisical, 76 

testing the movement of, during respiration, 

topographical anatomy of, 68 
Thorn-apple crystals in urine, 389 
Thought, examination of power of, 437 
Threads, gonorrheal, in urine, 375 

of mucus in sputum, 150 
Thrill, hydatid, 292 
Thrombosis, venous, 229 
Thrush, coating of tongue by, 255 

-fungus, recognition of, 257 

-spore in feces, 349 
Thumb, movements of, 499 
Thyreo-arytaenoideus internus, 54I 
Thyroid gland, murmurs over, 223 
Tinnitus aurium, 523 

Tissier on formation of urobilin in liver, 43 
Tobacco amblyopia, appearance of fundus of 
eye in, 548 



INDEX. 



599 



Tobacco amblyopia, central scotoma in, 521 
Toluylendiamin, poisoning by, causes hemato- 

hepatogenous icterus, 401 
Tongue, atrophy of, 494 

circumscribed swelling of, 254 

coating of, 255 

color of, 254 

dryness of, 254 

electric stimulation of, 471 

enlargement of, 254 

examination of, 254 

hardness of, 254 

mulberry, 254 

-muscles, functions of, 494 

paralysis of, 494 

scars on, 254, 255 

trembling of, 254 

wounds of, 254 
Tonic spasms, 488 

when occur, 490 
Tonsil, abscess of, 259 

ulcers of, 259 
Tonsillitis, follicular, tonsils in, 258 

tonsils in, 258 
Tonsils, a seat of origin of septicopyemic dis- 
ease, 258 

entrance of infectious diseases by, 257 

hypertrophied, 258 

in diphtheria, 258 

syphilitic scars on, 258 
Tonus of paralyzed muscles, 456 
Toothache from disease of the ear, 523 
Topography of abdomen, 268 
Torula cerevisise in vomit, 331 
Touch, sense of, testing of, 439 
Toxic paralyses, reaction of degeneration in, 

484 
Trachea, casts of, 149 

normal percussion-sound over, 105 

tympanitic sound over, 97 
Tract of deep sensibility, 420 
Tracts, centripetal, 419 

motor, 416 

sensitive, 419 
Transition breathing, 127 
Trapezius, paralysis of, effect of, 496 
Traube, attempt to explain Cheyne-Stokes 
respiration, 83 

reference to, as an improver of percussion, 92 

sound over crural artery in aortic insuffic- 
iency, 122 

theory of causation of moist rales, 129 
Traube's halfmoon-shaped space, 270, 275 
Traumatic hysteria, concentric narrowing of 
field of vision in, 521 

neurosis, concentric narrowing of field of 
vision in, 521 
Trautmann's pneumatic ear-speculum, 546 
Treatment, effect of, determined by action of 

pulse, 218 
Trembling, 489 
Tremor, 489 

alcoholic, 489 

intention, 489 

mercurialis, 489 

saturninus, 489 

senihs, 489 



Trichina spiralis, 345 
Trichinosis, 345 
cyanosis in, 39 
frequent respiration in, 84 
Trichocephalus dispar, 345 
Trichomonas vaginalis in urine, 383 
Tricuspid insufficiency, relative, failure of 
pulmonary heart-sound in, 188 
stenosis, effect of, 168 
valve, auscultation of sound of, 184 
Trigeminus, course of, 418 
Triple phosphate in sputum, 157 

in urine, 389 
Trismus, tonic spasms in, 490 
Trommer's test for sugar in urine, 402 
Tropaolin reaction, 317 
Tubercle bacilli, 552 
in blood, 246 
in feces, 353 
in sputum, 159 

microscopical demonstration of, 159 
in urine, 383 
staining of, 160, 1 61 
of choroid, 547 
Tubercular deposits, tympanitic sound over, 

113 

ulceration of larynx, 540 
Tuberculosis, acute miliary, enlargement of 
spleen in, 298 
frequent pulse in, 205 
azoospermia in, 413 
casts in urine in, 380 
Charcot-Leyden crystals in, 157 
choroidal tubercle in, 547 
color of face in, 37 
deepening of supraclavicular depressions in, 

73 

dicrotic pulse in, 213 

dyspnea in, 85 

elastic fibers in sputum of, 152 

fever of, 57 

fibrin in urine with, 398 

hemorrhage from lungs in, 146 

hemorrhagic exudation in, 139 

intestinal, pain on palpation of intestines in, 
. . 277 _ _ 

miliary, pleuritic friction-sounds in, 132 

of apex of lung, altered vesicular breath- 
ing in, 124 
resonance in, no 

of brain, poor nutrition in, 525 

of intestine, Charcot's crystals in feces of, 

349 
of larynx, 68 

swelling in, 538 
of lungs, remittent fever in, 61 

shown by tubercle bacillus, 162 
of lymphatic glands, absorption of fats in, 

of palate and pharynx, bacteriological deter- 
mination of, 260 

of pericardium, friction-sound in, 199 

of urinary apparatus, shreds of tissue in 
urine of, 379 
thickening or tenderness of ureters in, 
360 

pulmonary, Curschmann's spirals in, 155 



6oo 



INDEX. 



Tuberculosis, pulmonary, hydrochloric acid in 
stomach in, 324 
red border upon gums in, 254 
shrinking of omentum in, 302 
tubercle of choroid in, 547 
tympanitic sound in, 98 
ulceration of larynx in, 539 
urogenital, tubercle bacilli in urine of, 383 
Tuberculous infiltration and ulceration of 
larynx, paleness of mucous mem- 
brane in, 537 
Tumors, expansion of thorax in, 77 
dyspnea from, 88 
in lung, percussion-sound of, lOl 
in region of stomach, 272 
melanotic, color of urine from, 371 
neuralgia from pressure of, 447 
of bladder, hematuria in, 376 
of brain, anosmia from, 524 

catalepsy rare in, 492 

central vomiting in, 326 

choked disk in, 547 

disturbance of consciousness in, 437 

imbecility from, 438 

migraine in, 447 

vertigo in, 438 
of chest, dyspnea in, 85 

-cavity a cause of cyanosis, 39 

sensation of resistance over, 102 

tympanitic sound in, 1 12 
of chest-wall, diminished vesicular breath- 
ing in, 124 
of intestine, palpation of, 279 

percussion of, 280 
of kidney, detection of, 357 

diagnosis of, from ovarian tumor, 358 

differential diagnosis of, 359 

hematuria in, 376 

movable, 358 

percussion of, 358 

tenderness over, 357 
of larynx a cause of cyanosis, 38 
of liver change form of liver, 291 

dulness in, 295 
of lungs, percussion-sound in, 1 10 

raspberry-jelly sputum in, 146 
of meninges, sugar in cerebrospinal fluid 

in, 435 
of rectum, examination of, 279 
of spleen, 298 

pulsating, 298 
of stomach, dulness on percussion, 275 
of vertebrae, sensitiveness of spine to press- 
ure in, 434 _ 
within chest, bronchial breathing in, 125 
Turban (C.) on curves of fever in phthisis, 62 
Tiirck's reflector for examining larynx, 535 
Turpentine, odor of urine after taking, 373 

-poisoning, glycosuria in, 401 
Tympanites, distention of abdomen in, 278 
Tympanitic deadened sound, 113 
sound, 94 

change of pitch of, 114 

closed, 97 

conditions in which it is heard, 97 

dull, 95 

open, 97 



Tympanitic sound over stomach, 273 

pathological occurrence of, 112 

what determines the pitch of, 97 
Typhlitis, pain on palpation of right iliac 
fossa, 277 
resistance in neighborhood of cecum in, 283 
Typhoid bacilli in urine, 385 
fever, bacilli of, 351, 550 

bacillus of, in blood, 246 

bloody stools in, 339 

Charcot's crystals in feces of, 349 

Cheyne-Stokes respiration in, 83 

course of temperature in, 59 

crystals of ammoniaco-magnesian phos- 
phate in stools of, 349 

dicrotic pulse in, 213 

diminution of white blood-corpuscles in, 
242 

distention of abdomen in, 278 

disturbances of consciousness in, 437 

enlargement of spleen in, 298 

entrance of, through tonsils, 258 

frequent pulse in, 205 

glycosuria in, 402 

headache in, 447 

hemoglobinuria in, 370 

incontinentia alvi in, 528 

leucin and tyrosin in urine of, 390 

pain on pressure over intestines in, 277 

peptonuria with, 398 

position of children in bed in, 29 

roseola in, 44 

serum-reaction in, 247 

spermatozoa in urine of, 379 

stools in, 336 

trembling of tongue in, 254 

ulceration of larynx in, 539 

Widal test for, 247, 551 
Typhus abdominalis. See Typhoid fever. 

bacillus, 550 
fever, cutaneous hemorrhage in, 46 

roseola in, 44 
slow, 60 
Tyrosin in sputum, 157 
in urine, 390 

Uffelmann on determination of lactic acid 

in stomach, 318 
Uffelmann's test, 318 
Uhthoff on light rigidity of pupil in syphilis 

of central nervous system, 518 
Ulcer of stomach, bloody feces in, 339 
blood in stools of, 329 
bloody vomit in, 329 
hypersecretion in, 325 
normal digestion in, 324 
perforating, hyperacidity in, 325 
superacidity in, 325 

white blood-cells in stomach-contents in, 
316 
Ulceration of large intestine, bloody stools in, 
338 
purulent stools in, 339 
of larynx, 539 

and trachea, emphysema in, 49 
syphilitic, 539 
tubercular, 540 



INDEX. 



60 1 



Ulceration of rectum, odor of stools in, 336 
of trachea and bronchial tubes, cartilage in 

sputum in, 148 
Ulcers of intestine, tuberculous, tubercle 

bacilli in feces of, 353 
Ulcus rotundum, hyperacidity in, 325 
Ulnar nerve, electrical stimulation of, 472 
Umbilicus, obliteration of, in ascites, 282 
Undefined breathing, 127 
Undigested food in stools, 336, 337, 347 
Ungar on oxalate of lime in sputum of asthma, 

157 
Unilateral hypoglossal paralysis, 494 
Unverricht, systolia alterans, 175 
Urate of ammonium in urine, 389 

of sodium and lime as a sediment in urine. 

Urea in saliva of nephritis, 256 
increase of, 392 

normal amount of, in urine, 365 
Uremia, 399 

central vomiting in, 326 
Cheyne-Stokes respiration in, Zt, 
coma from, 437 
diminution of urea in, 392 
dyspnea in, 525 
epileptiform spasms in, 490 
headache in, 447 
retinitis albuminurica in, 547 
symptoms of, 399 
Uremic coma, 399 
Ureters, examination of, 359 

obstruction of, diminished quantity of urine 

in, 368 
palpation of, 359 
Urethra, burning in, from concentration of 

urine, 361 
Urethritis, white blood-corpuscles and pus in 

urine of, 377 
Urethrorrhoea ex libidine, 413 
Uric-acid concretions in urine, 391 

crystals in urine, 386 
Uric acid hinders examination for sugar, 365 
in blood, 250 
of urine, 365 
test for, 381 
when increased, 392 
Uridrosis, 34 
Urina nervosa, 367 

spastica, 367 
Urinary apparatus, examination of, 355 

relation of disturbance of, to nervous 
diseases, 528 
concretions, 391 
testing of, 391 
constituents in solution, 365, 391 
sediments, 363, 365 
examination of, 374 
inorganic, 385 
of organic bodies, 375 
pathological, 374 
Urination, frequent, from concentration of 

urine, 361 
Urine, abnormal constituents of, 393 
acidity of, determination of, 373 
amphoteric reaction of, 365 
as affected by medicines and poisons, 410 



Urine, bacteria in, 361 
blood-corpuscles in, 365 
color and transparency of, 363 

in disease, 368 
concentrated, appearance of, 362 

effects of, 361 
concretions in, 391 
daily average amount of, 362 
diminished amount of, 367 
discoloration of, 368-371 
examination of, 360 
hydrothionic, 373 
incontinence of, 528 
increased amount of, 366 
involuntary passage of, when occurs, 

528 
manner of passing, 361 
micro-organisms in, 361 
mixed with feces, odor of, 373 
mode of procedure in examining, 361 
normal, 362 
odor of, 365 

due to medicines, 373 
pathological, 373 
pathological, 366 
reaction of, 364 

in disease, 372 
residual, 368 
retention of, 528 
should be drawn with catheter when there 

is unconsciousness, 362 
specific gravity of, 363 

determination of, 364 
in disease, 372 
spectroscopic examination of, for blood, 
400 
! Urinometer, 364 
Urobilin, abnormal amount, in urine, 369 
-icterus, 42, 369 
in urine, 42 
of fever, 369 
tests for, 370 
of urine, 362 
Uva ursi, color of urine after taking, 371 

Vacuoles, 249 

Vagi, compression of, recurrent paralysis with, 

543 
Vagus, irritation of, retardation of pulse in, 

204 
Valleix's points, 448 
Valve, stenosis of, 168 
Valvular disease, combined, pulse in, 217 
of heart, hematuria in, 375 
insufficiency and its effects, 168 
Varices, 46 
Variola, leucin and tyrosin in urine in, 

390 
ulceration of larynx m, 539 
Vasomotor disturbances in nervous diseases, 

526 
Vegetable parasites in stools, 349 

in urine, 383 
Veins, auscultation of, 230 
examination of, 223 
increased fulness of, 223 
inspection and palpation of, 223 



602 



INDEX. 



Veins of neck, dififerential diagnosis of different 
kinds of pulse in, 228 
undulations in, 226 
phenomena of circulation in, 229 
Venous engorgement, causes of, 224 
enlargement of spleen in, 298 
humming, 230 
liver-pulse, 228 
pulse, 226 

ascending, 229 

double positive, in hemisystole, 229 
positive, tracing of, 227 
progressive, 229 
systolic, 229 
tracing of, 226 
stasis, bloody vomit in, 329 
thrombosis, 229 
Ventricle, left, hypertrophy and dilatation of, 
shown by displacement of apex- 
beat, 173, 174 
hypertrophy of, large pulse in, 208 
hypertrophy of, shown by strengthened 
sound of corresponding valve, 188 
Vermiform process, effect of lesions of, 427 
*' Verschlusszeit," 172 
Vertebral canal, puncture of, 434 
column. See Spinal column. 
Vertigo, 438 

ab am-e Isesa, 438 
a storaacho laeso, 438 
of the eye, 514 
Vesicular breathing, 1 21 
alterations of, 124 
special peculiarities of, 123 
Vessels supplying brain, 421 
Vicarious emphysema, 76 
Vierordt (H.), method of measuring strength 
of heart-sounds, 188 
on slowed coagulation of blood in chronic 

disturbances of nutrition, 250 
(K.), originator of sphygmography, 211 
Virchow on nature of epithelium in sputum. 

Vision, field of, concentric narrowing of, 521 
testing of, 520 
sharpness of, testing of, 519 
subjective sensations of, 522 
Visual ammesia, 506 
Vital capacity, 141 

Vocal cords, movements of, in phonation, 537 
position of, in paralysis, 542, 543 
fremitus a means of distinguishing between | 
pneumonia and pleuritic exudation, 

134 
testing for, 89 
variations of, 134 
weakness or suppression of, 134 
Voice, alteration of, in disease, 67 

auscultation of, 133 
Voluntary muscles, innervation, function, and 
diseases that disturb them, 492 
spasms of, 488 
Vomicae, tympanic sound over, 1 13 
Vomit, bilious, 328 
bloody, 328, 329 
chemical examination of, 327 
coffee-ground, test for hemin in, 330 



Vomit, color of, 328 

examination of, 327 

macroscopical appearance of, 327 

microscopical examination, 331 

mucous, 328 

corpuscles in, 331 

odor of, 332 

quantity of, 327 

reaction of, 332 

round worms in, 331 

starch-grains in, 331 

watery, watery-mucous, and mucous, signifi- 
cance of, 328 
Vomiting, act of, described, 326 

central, diseases in which it occurs, 326 

fecal, 330 

frequency of, 327 

in brain disease, 527 

in diseases of abdominal organs other than 
the stomach, 326 

kinds of, clinically distinguished, 326 

low specific gravity of urine in, 372 

of blood, 328, 329 

of pus, 330 

phenomena associated with, 326 

reflex, 326 

time when it begins, 327 
Vomitus matutinus potatorum, 327 

of drunkards, 327 
Von Basch on cause of dyspnea, 86 
Von Frey on " recoil " of pulse-nerve, 212 

sphygmograph of, 211 
Von Jafife, test for indican in urine, 369 
Von Jaksch on alkalescence of blood in 
diabetes, 250 

on auto-intoxication with acetonuria, 409 

on diaceturia, 407 

on phenyl-hydracin test for sugar, 403 

on prognostic value of leukocytosis in 
pneumonia, 242 

on starch-corpuscles in sputum of pulmonary 
gangrene, 155 

on urobilin-icterus, 42 

"vacuoles," 249 
Von Jaksch's modification of Sjoqvist's method, 

319 

Von Limbeck on proportion of white blood- 
corpuscles to red ones, 242 

Von Mering on absorption by stomach-walls, 

307 
on secretion of water by stomach, 307 
Von Noorden on glycosuria, 402 
Von Ziemssen, laryngitis hypoglottica, 538 
on distention of stomach with carbonic 

acid, 272 
on relations of size of body to vital capacity, 

141 
pulsus dififerens, 215 
Von Ziemssen's method of obtaining blood 
for examination, 251 

Wagner (E.), described peculiar sputum 

from hysteria, 146 
Waldenburg's pneumatometer, 141 
Wandering kidney, 357 

left kidney, differentiation from wandering 

spleen, 359 



INDEX. 



603 



Wandering liver, 289 

absence of liver-dulness in, 296 
right kidney, differentiation from distended 

gall-bladder or echinococcus, 359 
spleen, 298, 299 
Wasting diseases, heart-murmurs in, 197 
Water, absorption of, by stomach, 307 
-brash of drunkards, vomiting in, 328 
whistling, 131 
W^atery stools, 338 

vomit, 328 
Waxy casts, 380 
Weber's syndrome, 427 
Weichselbaum on pus-cocci in urine, 385 
Weigert's method of staining tubercle bacilli, 

160 
Weight, importance of changes in, 31 

relation of, to height, 32 
Weil, "deep percussion" of intestine, 281 
on displacement of border of lungs in ex- 
piration, 109 
of lower border of lungs in lying down, 
109 
on dulness in Traube's space in health, 

275 
on feeling of resistance, 102 
on hne of relative heart-dulness, 180 
on occurrence of thigh-sound, 99 
on percussion of spleen, 299, 301 
reference to, as improver of percussion, 

92 
sound over crural artery in mitral stenosis, 

22 
Wernicke on disturbance of vision from 

choked disk, 547 
on motor aphasia, 507 
on sensory aphasia, 506 
Wertheim's method of cultivating gonococcus, 

549 
Westphal on intermitting general paralysis, 

485 
paradoxical contractions, 486 
Westphal's sign, 460 

view of tendon-reflexes, 461 
WTietstone crystals of uric acid in urine, 
387 



W'histling rales, significance of, 128 
White blood-corpuscles. See Blood-corpus- 
cles. 
in sputum, 150 
Whitish sediment of urine, 363 
Whooping-cough, cough in, 143 
expiratory bulging in, 88 
microbe of, 164 
Widal-test for typhoid fever, 247 
Widal's reaction for typhoid bacilli, 551 
Williams's tracheal sound, 98, 106, 113 
Wintrich, reference to, as improver of old 
percussion, 92 
as introducer of percussion-hammer, 93 
Wintrich's change of sound, 98, 114 

confounded with Williams's tracheal 

sound, 1 14 
interrupted, 114 
Wire pulse, 210 
Woillez"s cyrtometer for measuring thorax, 

140 
Wolpe on oxybutyric acid in urine, 407 
Word-deafness, 506 

testing for, 509 
Wounds of the lungs, emphysema from, 50 
W^riting, center for, 505 

diagnostic value of character of, 513 
loss of power of, in atactic aphasia, 508 
power of, how acquired, 503 
Wunderlich's table of temperatures, 55 

Xanthin, concretions of, in urine, 391 

Yeast- FUxNGUS in feces, 349 

in urine, 385 

in vomit, 331 
Yellow atrophy of liver. See Atrophy. 

fever, bloody vomit in, 329 

skin, 40 

Ziehl-Neelsen method of staining tubercle 

bacilli. 161 
Ziehl on tract of taste, 421 
Zimmerlin on reaction of degeneration in 

myopathic muscular atrophy, 483 
Zygomatic nerve, distribution of, 448 



CATALOGUE 

OF THE 

MEDICAL PUBLICATIONS 

OF 

W. B. SAUNDERS, 

No. 925 WALNUT STREET, PHILADELPHIA. 



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See pages 30, 3 J, for a List of Contents classified according to subjects. 



LATEST PUBLICATIONS. 



American Text-Book of Genito-Urinary and Skin Diseases. Page 4. 

American Text-Book of Diseases of Children — Rev. Edition. Page 3. 

American Text-Book of Gynecology — Revised Edition. See page 4. 

American Year-Book of Medicine and Surgery. See page 6. 

Anders' Practice of Medicine — Revised Edition. See page 6. 

Vierordt's Medical Diagnosis — Fourth (Revised) Edition. See page 28. 

Van Valzah and Nisbet's Diseases of the Stomach. See page 28. 

Church and Peterson's Nervous and Mental Diseases. See page 9. 

Da Costa's Surgery — Revised and Enlarged Edition. See page 10. 

Saunders' Medical Hand-Atlases. See page 2. 

Saunders' Pocket Formulary — Fifth (Revised) Edition. See page 24. 

Keen's Surgical Complications of Typhoid Fever. See page J5. 

Griffith on The Baby — Revised Edition. See page 12. 

Butler's Materia Medica and Therapeutics — Revised Edition. Page 8. 

Stevens' Practice of Medicine — Fifth (Revised) Edition. See page 27. 

De Schweinitz' Diseases of the Eye — Revised Edition. See page 10. 

Chapin's Compendium of Insanity. See page 8. 

Senn's Genito-Urinary Tuberculosis. See page 25. 

Penrose's Diseases of Women. See page 18, 

McFarland's Pathogenic Bacteria — Revised Edition. See page 17. 

Macdonald's Surgical Diagnosis. See page 16. 

Moore's Orthopedic Surgery. See page 17. 

Mallory and Wright's Pathological Technique. See page 16. 



Saunders' Medical Hand-Atlases. 

The series of books included under this title are authorized translations into English 
of the world-famous 

Lehmann Medicinische Hand=atianten. 

For scientific accuracy, pictorial beauty, compactness, and cheapness these books 
surpass any similar volumes ever published. Each volume contains from 

50 to 100 Colored Plates, 

besides numerous other illustrations in the text. These colored plates have been executed 
by the most skilful German lithographers, in some cases twenty or more impressions being 
required to obtain the desired result. There is a full and appropriate description of each 
plate (printed, for convenience, opposite the plate) , together with a condensed outline of 
the subject to which the book is devoted. 

The same careful and competent editorial supervision will be secured in the 
English edition as in the originals. The translations will be directed and edited by the 
leading American specialists in the different subjects. 

The great advantage of natural pictorial representation is indisputable. For lasting and 
practical knowledge, one accurate illustration is better than several pages of dry 
description. 

These Atlases offer a ready and satisfactory substitute for clinical observation, avail- 
able only to the residents of large medical centers ; and with such persons the requisite 
variety is seen only after long years of routine hospital service. 

By reason of their projected universal translation and reproduction, affording inter- 
national distribution, the publishers have been enabled to secure for these Atlases the best 
artistic and professional talent, to produce them in the most elegant style, and yet to 
offer them at a price heretofore unapproached in cheapness. The success of the under- 
taking is demonstrated by the fact that volumes have already appeared in German, English, 
French, Italian, Russian, Spanish, Danish, Swedish, and Hungarian. 

While appreciating the value of such colored plates, the profession has heretofore been 
practically debarred from purchasing similar works because of their extremely high price, 
made necessary by the limited sale and the enormous expense of production. The very 
lov4r price of these Atlases will place them within the reach of even the novice in practice. 

NOW READY. 

Atlas of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited 
byAupusTus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic; At- 
tending Physician to the Philadelphia Hospital. 68 colored plates, and 64 illustrations in the text. 
Cloth, I3.00 net. 

Atlas of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited by Frederick Peter- 
son, M.D., Clinical Professor of Mental Diseases, Woman's Medical College, New York; Chief 
of Clinic, Nervous Dept., College of Physicians and Surgeons, New York. With 120 colored fig- 
ures on 56 plates, and 193 beautiful half-tone illustrations. Cloth, $3.50 net. 

Atlas of Diseases of the Larynx. By Dr. L. Grunwald, of Munich. Edited by Charles P. 
Grayson, M.D., Lecturer on Laryngology and Rhinology in the University of Pennsylvania; 
Physician-in-Charge, Throat and Nose Department, Hospital of the University of Pennsylvania. 
With 107 colored figures on 44 plates, and 25 text-illustrations. Cloth, $2.50 net. 

Atlas of Operativ Surgery. By Dr. O. Zuckerkandl, of Vienna. Edited by J. Chalmers 
DaCosta, M.D., Clinical Professor of Surgery, Jefierson Medical College, Philadelphia; Surgeon 
to the Philadelphia Hospital. With 24 colored plates, and 2x7 text illustrations. Cloth, I3.00 net. 

Atlas of Syphilis and the Venereal Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited 
by L. Bolton Bangs, M.D., late Professor of Genito-Urinary and Venereal Diseases, New York 
Post-Graduate Medical School and Hospital. With 71 colored plates from original water-colors, 
and 16 black-and-white illustrations. Cloth, I3.50 net. 

IN PREPARATION, 

Atlas of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited by G. E. 
DE ScHWEiNiTZ, M.D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia. 
With 100 colored illustrations. 

Atlas of Skin Diseases. By Prof. Dr. Franz Mracek, of Vienna. With 80 colored plates from 
original water-colors. 

Atlas of Pathological Histology. Atlas of Operative Gynecology. 

Atlas of Orthopedic Surgery. Atlas of Psychiatry. 

Atlas of General Surgery. Atlas of Diseases of the Ear. 




THE AMERICAN TEXT-BOOK SERIES. 

AN AMERICAN TEXT=BOOK OF APPLIED THERAPEUTICS. 

By 43 Distinguished Practitioners and Teachers. Edited by James C. 
Wilson, M.D., Professor of the Practice of Medicine and of Clinical 
Medicine in the Jefferson Medical College, Philadelphia. One hand- 
some imperial octavo volume of 1326 pages. Illustrated. Cloth, 
^7.00 net; Sheep or Half Morocco, ^8.00 net. Sold by Subscription. 

" As a work either for study or reference it will be of great value to the practitioner, as 
it is virtually an exposition of such clinical therapeutics as experience has taught to be ol 
the most value. Taking it all in all, no recent publication on therapeutics can be compared 
with this one in practical value to the working physician." — Chicago Clinical Review. 

*' The whole field of medicine has been well covered. The. work is thoroughly prac- 
tical, and while it is intended for practitioners and students, it is a better book for the general 
practitioner than for the student. The young practitioner especially will find it extremely 
•suggestive and helpful." — The Indian Lancet. 

AN AMERICAN TEXT=BOOK OF THE DISEASES OF CHILDREN. 
Second Edition, Revised. 

By (iT, Eminent Contributors. Edited by Louis Starr, M.D., Physi- 
cian to the Children's Hospital, Philadelphia, etc.; assisted by 
Thompson S. Westcott, M.D., Attending Physician to the Dispen- 
sary for Diseases of Children, Hospital of the University of Pennsyl- 
vania. In one handsome imperial octavo volume of 1250 pages, 
profusely illustrated. Cloth, ^7.00 net; Sheep or Half Morocco, 
^8.00 net. Sold by Subscription. 

**This is far and away the best text-book on children's diseases ever published in the 
English language, and is certainly the one which is best adapted to American readers. 
We congratulate the editor upon the result of his work, and heartily commend it to the 
attention of every student and practitioner. ' ' — American Journal of the Medical Sciences. 

AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, 
NOSE, AND THROAT. 

By 58 Prominent Specialists. Edited by G. E. de.Schweinitz, M.D., 
Professor of Ophthalmology in the Jefferson Medical College, Phila- 
delphia ; and B. Alexander Randall, M.D., Professor of Diseases 
of the Ear in the University of Pennsylvania and in the Philadelphia 
Polyclinic. Ready soon. 



lUtistrated Catalogue of the ** American Text-Books'' sent free upon application. 



4 Medical Publications of W. B. Saunders. 

AN AMERICAN TEXT=BOOK OF QENITO=URINARY AND SKIN 
DISEASES. 

By 47 Eminent Specialists and Teachers. Edited by L. Bolton 
Bangs, M.D. , Late Professor of Genito-Urinary and Venereal Diseases, 
New York Post-Graduate Medical School and Hospital ; and W. 
A. Hardaway, M.D., Professor of Diseases of the Skin, Missouri 
Medical College. Imperial octavo volume of 1229 pages, with 300 en- 
gravings and 2D full-page colored plates. Cloth, ^7.00 net; Sheep 
or Half Morocco, ^8.00 net. Sold by Subscription. 

"This volume is one of the best yet issued of the publisher's series of ' American Text- 
Books.' The list of contributors represents an extraordinary array of talent and extended 
experience. The book will easily take the place in comprehensiveness and value of the 
half dozen or more costly works on these subjects \vhich have heretofore been necessary to 
a well-equipped library." — Neiv York Polyclinic. 

AN AMERICAN TEXT=BOOK OF GYNECOLOGY, MEDICAL AND 
SURGICAL. Second Edition, Revised. 

By 10 of the Leading Gynecologists of America. Edited by J. M. 
Baldy, M. D., Professor of Gynecology in the Philadelphia Polyclinic, 
etc. Handsome imperial octavo volume of over 700 pages, with 341 
illustrations in the text, and 2i^ colored and half-tone plates. Cloth, 
^6.00 net; Sheep or Half Morocco, ^7.00 net. Sold by Subscription. 
" It is practical from beginning to end. Its descriptions of conditions, its recommen- 
dations for treatment, and above all the necessary technique of different operations, are 
clearly and admirably presented. . . . It is well up to the most advanced views of the 
day, and embodies all the essential points of advanced American gynecology. It is destined 
to make and hold a place in gynecological literature which will be peculiarly its own." — 
Medical Record, New York. 

AN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND TOXI- 
COLOGY. 

Edited by Frederick Peterson, M.D., Clinical Professor of Mental 
Diseases in the Woman's Medical College, New York; Chief of Clinic, 
Nervous Department, College of Physicians and Surgeons, New York ; 
and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy, 
and Toxicology in Rush Medical College, Chicago. In Preparation. 

AN AMERICAN TEXT=BOOK OF OBSTETRICS. 

By*i5 Eminent American Obstetricians. Edited by Richard C. Nor- 
Ris, M.D.; Art Editor, Robert L. Dickinson, M.D. One handsome 
imperial octavo volume of over 1000 pages, with nearly 900 beautiful 
colored and half-tone illustrations. Cloth, $7.00 net; Sheep or Half 
. Morocco, $8.00 net. Sold by Subscription. 

" Permit me to say that your American Text-Book of Obstetrics is the most magnificent 
medical work that I have ever seerf. I congratulate you and thank you for this superb work, 
which alone is sufficient to place you first in the ranks of medical publishers." — Alexander 
J. C. Skene, Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y. 

" This is the most sumptuously illustrated work on midwifery that has yet appeared. In 
the number, the excellence, and the beauty of production of the illustrations it far surpasses 
every other book upon the subject. This feature alone makes it a work which no medical 
library should omit to purchase." — British Medical Journal. 

"As an authority, as a book of reference, as a ' working book ' for the student or prac- 
titioner, we commend it because we believe there is no better." — American Journal of the 
Medical Sciences. 

Illustrated Catalogue of the ^^American Text-Books ** sent free upon application^ 



Medical Publications of W. B. Saunders, 5 

AN AMERICAN TEXT=BOOK OF PATHOLOGY. 

Edited by John Guiteras, M.D., Professor of General Pathology and 
of Morbid Anatomy in the University of Pennsylvania ; and David 
RiESMAN, M.D., Demonstrator of Pathological Histology in the 
University of Pennsylvania. In Preparatio7i. 

AN AMERICAN TEXT=BOOK OF PHYSIOLOGY. 

By I o of the Leading Physiologists of America. Edited by William 
H. Howell, Ph.D., M.D., Professor of Physiology in the Johns Hop- 
kins University, Baltimore, Md. One handsome imperial octavo 
volume of 1052 pages. Illustrated. Cloth, $6.00 net ; Sheep or Half 
Morocco, ^7.00 net. Sold by Subscription. 

" We can commend it most heartily, not only to all students of physiology, but to every 
physician and pathologist, as a valuable and comprehensive work of reference, written by 
men who are of eminent authority in their own special subjects." — London Lancet. 

" To the practitioner of medicine and to the advanced student this volume constitutes, 
we believe, the best exposition of the present status of the science of physiology in the 
English language." — American Journal of the Medical Sciences. 

AN AMERICAN TEXT=BOOK OF SURGERY. Second Edition. 

By 13 Eminent Professors of Surgery. Edited by William W. Keen, 
M.D., LL.D., and J. William White, M.D., Ph.D. Handsome 
imperial octavo volume of 1250 pages, vi^ith 500 wood-cuts in the text, 
and 39 colored and half-tone plates. Thoroughly revised and enlarged, 
with a section devoted to '' The Use of the Rontgen Rays in Surgery." 
Cloth, ^7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Sub- 
scription. 

" Personally, I should not mind it being called THE Text-Book (instead of A Text- 
Book) , for I know of no single volume which contains so readable and complete an account 
of the science and art of Surgery as this does." — Edmund Owen, F.R.C.S., Member of 
the Board of Examiners of the Royal College of Surgeons, England. 

" If this text-book is a fair reflex of the present position of American surgery, we must 
admit it is of a very high order of merit, and that English surgeons will have to look very 
carefully to their laurels if they are to preserve a position in the van of surgical practice." — 
London Lancet. 

AN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE 
OF MEDICINE. 

By 12 Distinguished American Practitioners. Edited by William 
Pepper, M.D., LL.D., Professor of the Theory and Practice of Medi- 
cine and of Clinical Medicine in the University of Pennsylvania. Two 
handsome imperial octavo volumes of about 1000 pages each. Illus- 
trated. Prices per volume : Cloth, $5.00 net ; Sheep or Half Morocco, 
^6.00 net. Sold by Subscription. 

" I am quite sure it will commend itself both to practitioners and students of medicine, 
and become one of our most popular text-books." — Alfred Loomis, M.D., LL.D., Pro- 
fessor of Pathology and Practice of Medicine, University of the City of New York. 

" We reviewed the first volume of this work, and said : ' It is undoubtedly one of the 
best text-books on the practice of medicine which we possess.' A consideration of the 
second and last volume leads us to modify that verdict and to say that the completed work 
is in our opinion the best of its kind it has ever been our fortune to see. " — New York Medical 
Journal. 

Illustrated Catalogue of the ** American Text-Books'' sent free upon application. 



6 Medical Pablications of W, B, Saunders. 

AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. 

A Yearly Digest of Scientific Progress and Authoritative Opinion in all 
branches of Medicine and Surgery, drawn from journals, monographs, 
and text-books of the leading American and Foreign authors and 
investigators. Collected and arranged, with critical editorial com- 
ments, by eminent American specialists and teachers, under the general 
editorial charge of George M. Gould, M.D. One handsome imperial 
octavo volume of about 1200 pages. Uniform in style, size, and 
general make-up with the "American Text-Book" Series. Cloth, 
^6.50 net; Half Morocco, ^7.50 net. Sold by Subscription. 

*' It is difficult to know which to admire most — the research and industry of the distin- 
guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the 
wealth and abundance of the contributions to every department of science that have been 
deemed worthy of analysis. . . . It is much more than a mere compilation of abstracts, 
for, as each section is entrusted to experienced and able contributors, the reader has the 
advantage of certain critical commentaries and expositions . . . proceeding from writers 
fully qualified to perform these tasks. . . . It is emphatically a book which should find 
a place in every medical library, and is in several respects more useful than the famous 
* Jahrbiicher ' of Germany." — London Lancet. 

ANDERS' PRACTICE OF MEDICINE. Second Edition. 

A Text=Book of the Practice of Medicine. By James M. Anders, 
M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of 
Clinical Medicine, Medico- Chirurgical College, Philadelphia. In one 
handsome octavo volume of 1287 pages, fully illustrated. Cloth, 
^5.50 net; Sheep or Half Morocco, ^6.50 net. 

"It is an excellent book, — concise, comprehensive, thorough, and up to date. It is a 
credit to you ; but, more than that, it is a credit to the profession of Philadelphia — to us." 
James C. Wilson, Professor' of the Practice of Medicine and Clinical Medicine, Jeffeyson 
Medical College, Philadelphia. 

" I consider Dr. Anders' book not only the best late work on Medical Practice, but by 
far the best that has ever been published. It is concise, systematic, thorough, and fully up 
to date in everything. I consider it a great credit to both the author and the publisher." — 
A. C. CowPERTHWAlTE, President of the Lllinois Homeopathic Medical Association. 

ASHTON'S obstetrics. Fourth Edition, Revised. 

Essentials of Obstetrics. By W. Easterly Ashton, M.D., Pro- 
fessor of Gynecology in the Medico-Chirurgical College, Philadelphia. 
Crown octavo, 252 pages; 75 illustrations. Cloth, $1.00; interleaved 
for notes, $1.25. 

[See Saunders^ Question- Compe?ids , page 21.] 

«' Embodies the whole subject in a nut-shell. We cordially recommend it to our read- 
ers." — Chicago Medical Times. 

BALL'S BACTERIOLOGY. Third Edition, Revised. 

Essentials of Bacteriology ; a Concise and Systematic Introduction 
to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol- 
ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218 
pages; 82 illustrations, some in colors, and 5 plates. Cloth, $1.00; 
interleaved for notes, ^1.25. 

[See Saunders' Questio7i-Compe7ids, page 21.] 

" The student or practitioner can readily obtain a knowledge of the subject from a perusal 
of this book. The illustrations are clear and satisfactory."— yl/^^zV^/ i^^^^r^, New York. 



Medical Publications of W, B, Saunders, 7 

BASTIN'S BOTANY. 

Laboratory Exercises in Botany. By Edson S. Bastin, M.A., 
late Professor of Materia Medica and Botany, Philadelphia College of 
Pharmacy. Octavo volume of 536 pages, with 87 plates. Cloth, ^2.50. 

"It is unquestionably the best text-book on the subject that has yet appeared. The 
work is eminently a practical one. We regard the issuance of this book as an important 
event in the history of pharmaceutical teaching in this country, and predict for it an unquali- 
fied success." — Ahimni Report to the Philadelphia College of Pharmacy. 

"There is no work like it in the pharmaceutical or botanical literature of this country, 
and we predict for it a wide circulation." — Arnerican Journal of Pharmacy. 

BECK'S SURGICAL ASEPSIS. 

A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to 
St. Mark's Hospital and the New York German Poliklinik, etc. 306 
pages; 65 text-illustrations, and 12 full-page plates. Cloth, ^1.25 net. 

"An excellent exposition of the 'very latest' in the treatment of wounds as practised 
by leading German and American surgeons." — Birmingham (Eng.) Medical Review. 

"This little volume can be recommended to any who are desirous of learning the details 
of asepsis in surgery, for it will serve as a trustworthy guide." — Londojz Lancet. 

BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND 
OPERATIONS. 
Obstetric Accidents, Emergencies, and Operations. By L. Ch. 

BoiSLiNiERE, M.D., late Emeritus Professor of Obstetrics, St. Louis 
Medical College. 381 pages, handsomely illustrated. Cloth, ^2.00 net. 

" It is clearly and concisely written, and is evidently the work of a teacher and practi- 
tioner of large experience." — British Medical Journal. 

" A manual so useful to the student or the general practitioner has not been brought to 
our notice in a long time. The field embraced in the title is covered in a terse, interesting 
way." — Yah Medical Journal. 

BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. 
Essentials of Medical Physics. By Fred J. Brockway, M.D., 
Assistant Demonstrator of Anatomy in the College of Physicians and 
Surgeons, New York. Crown octavo, 330 pages; 155 fine illustrations. 
Cloth, ^i.oo net ; interleaved for notes, ^1.25 net. 

[See Saunders'' Question- Compends, page 21.] 

" The student who is well versed in these pages will certainly prove qualified to com- 
prehend with ease and pleasure the great majority of questions involving physical principles 
likely to be met with in his medical studies." — Ainerican Practitioner and News. 

"We know of no manual that affords the medical student a better or more concise 
exposition of physics, and the book may be commended as a most satisfactory presentation 
of those essentials that are requisite in a course in medicine." — New York Medical Journal. 

'' It contains all that one need know on the subject, is well written, and is copiously 
illustrated." — Medical Record, New York. 

BURR ON NERVOUS DISEASES. 

A Manual of Nervous Diseases. By Charles W. Burr, M.D., 
Clinical Professor of Nervous Diseases, Medico-Chirurgical College, 
Philadelphia; Pathologist to the Orthopedic Hospital and Infirmary 
for Nervous Diseases; Visiting Physician to St. Joseph's Hospital, etc. 
In Preparation. 



8 Medical Publications of W, B, Saunders, 

BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- 
MACOLOGY. Second Edition, Revised. 
A Text=Book of Materia Medica, Therapeutics, and Pharma- 
cology. By George F. Butler, Ph.G., M.D., Professor of Materia 
Medica and of Clinical Medicine in the College of Physicians and 
Surgeons, Chicago; Professor of Materia Medica and Therapeutics, 
Northwestern University, Woman's Medical School, etc. Octavo, 860 
pages, illustrated. Cloth, ^4.00 net; Sheep, ^5.00 net. 

" Taken as a whole, the book may fairly be considered as one of the most satisfactory 
of any single-volume works on materia medica in the market," — Journal of the American 
Medical Association. 

*' The work is executed in a clear, concise, and practical manner, and should, meet with 
a hearty endorsement from the students of our up-to-date colleges. The book will be found 
a valuable work of reference for the practitioner." — American Medico-Surgical Bulletin. 

CASSELBERRY ON THE NOSE AND THROAT. 

Diseases of the Nose and Throat. By W. E. Casselberry, Pro- 
fessor of Laryngology and Rhinology in the Northwestern University 
Medical School, Chicago. In Preparation. 

CERNA ON THE NEWER REMEDIES. Second Edition, Revised. 
Notes on the Newer Remedies, their Therapeutic Applications 
and Modes of Administration. By David Cerna, M.D., Ph.D., 
formerly Demonstrator of and Lecturer on Experimental Therapeutics 
in the University of Pennsylvania ; Demonstrator of Physiology in the 
Medical Department of the University of Texas. Rewritten and 
greatly enlarged. Post-octavo, 253 pages. Cloth, ^1.25. 

" The appearance of this new edition of Dr. Cerna' s very valuable work shows that it 
is properly appreciated. The book ought to be in the possession of every practising physi- 
cian." — New York Medical Journal. 

CHAPIN ON INSANITY. 

A Compendium of Insanity. By John B. Chapin, M.D., LL.D., 
Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi- 
cian-Superintendent of the Willard State Hospital, New York ; Hon- 
orary Member of the Medico-Psychological Society of Great Britain, 
of the Society of Mental Medicine of Belgium. i2mo, 234 pages, 
illustrated. Cloth, ^1.25 net. 

The author has given, in a condensed and concise form, a compendium of Diseases of 
the Mind, for the convenient use and aid of physicians and students. The work will also 
prove valuable to members of the legal profession and to those who, in their relations to the 
insane and to those supposed to be insane, often desire to acquire some practical knowledge 
of insanity presented in a form that may be understood by the non-professional reader. 

CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. 
Second Edition, Revised. 
Medical Jurisprudence and Toxicology. By Henry C. Chapman, 
M.D., Professor of Institutes of Medicine and Medical Jurisprudence 
in the Jefferson Medical College of Philadelphia. 254 pages, with 55 
illustrations and 3 full-page plates in colors. Cloth, ^1.50 net. 

' "The best book of its class for the undergraduate that we know of." — New York 
Medical Times. 



Medical Publications of W, B, Saunders, 9 

CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 
Nervous and Mental Diseases. By Archibald Church, M.D., 
Professor of Mental Diseases and Medical Jurisprudence in the North- 
western University Medical School, Chicago ; and Frederick Peter- 
son, M.D., Clinical Professor of Mental Dis-^iases in the Woman's 
Medical College, New York ; Chief of Clinic, Nervous Department, 
College of Physicians and Surgeons, New York. In Preparation. 

CLARKSON'S HISTOLOGY. 

A Text=Book of Histology, Descriptive and Practical. By 

Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of 
Physiology in the Owen's College, Manchester; late Demonstrator of 
Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 
22 engravings in the text, and 174 beautifully colored original illustra- 
tions. Cloth, strongly bound, ^6.00 net. 

" The work must be considered a valuable addition to the list of available text-books, 
and is to be highly recommended." — New York Medical Journal. 

"This is one of the best works for students we have ever noticed. We predict that the 
book will attain a well-deserved popularity among our students." — Chicago Medical Recorder. 

"The volume is a most valuable addition to the armamentarium of the teacher." — 
Brooklyn Medical Journal. 

CLIMATOLOGY. 

Transactions of the Eighth Annual Meeting of the American 
Climatological Association, held in Washington, September 22-25, 
1 89 1. Forming a handsome octavo volume of 276 pages, uniform with 
remainder of series. (A limited quantity only.) Cloth, ^1.50. 

COHEN AND ESHNER'S DIAGNOSIS. 

Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- 
fessor of Clinical Medicine and Applied Therapeutics in the Philadel- 
phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical 
Medicine in the Philadelphia Polyclinic. Post-octavo, 382 pages; 55 
illustrations. Cloth, $1.50 net. 

[See Satmders^ Question- Co77ipends, page 21.] 

''We can heartily commend the book to all those who contemplate purchasing a 'com- 
pend.' It is modern and complete, and will give more satisfaction than many other works 
which are perhaps too prolix as well as behind the times." — Medical Review, St. Louis. 

CORWIN'S PHYSICAL DIAGNOSIS. 

Essentials of Physical Diagnosis of the Thorax. By Arthur 
M. CoRWiN, A.M., M.D., Demonstrator of Physical Diagnosis in Rush 
Medical College, Chicago ; Attending Physician to Central Free Dis- 
pensary, Department of Rhinology, Laryngology, and Diseases of the 
Chest, Chicago. 200 pages, illustrated. Cloth, flexible covers, ^1.25 net. 

"It is excellent. The student who shall use it as his guide to the careful study of 
physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good 
working knowledge of the subject." — Philadelphia Polyclinic. 

"A most excellent little work. It brightens the memory of the differential diagnostic 
signs, and it arranges orderly and in sequence the various objective phenomena to logical 
solution of a careful diagnosis." — Journal oj Nei'vous and Mental Diseases. 



10 Medical Publications of W. B. Saunders. 

CRAGIN'S GYNECOLOGY. Fourth Edition, Revised. 

Essentials of Gynaecology. By Edwin B. Cragin, M.D., Attend- 
ing Gynaecologist, Roosevelt Hospital, Out-Patients' Department, New 
York, etc. Crown octavo, 200 pages; 62 fine illustrations. Cloth, 
^i.oo; interleaved for notes, ^1.25. 

[See Saunders' Question- Compends, page 21.] 

*' A handy volume, and a distinct improvement on students' compends in general. No 
author who was not himself a practical gynecologist could have consulted the student's needs 
so thoroughly as Dr. Cragin has done." — Medical Record, New York. 

CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised. 

A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B., 
Professor of Comparative Pathology and Bacteriology, King's College, 
London. Octavo volume of 700 pages, with 273 engravings and 22 
original colored plates. Cloth, ^6.50 net; Half Morocco, ^7.50 net. 

'* To the student who wishes to obtain a good resume of what has been done in bacteri- 
ology, or who wishes an accurate account of the various methods of research, the book may 
be recommended with confidence that he will find there what he requires." — London Lancet, 

Da COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged. 
Modern Surgery, General and Operative. By John Chalmers 
DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical 
College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. 
Handsome octavo volume of 900 pages, profusely illustrated. Cloth, 
^4.00 net; Half Morocco, ^5.00 net. 

"We know of no small work on surgery in the English language which so well fulfils 
the requirements of the modern student." — Medico- Chirtcrgical Journal, Bristol, England. 

DE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition, 
Revised. 
Diseases of the Eye, A Handbook of Ophthalmic Practice. 

By G. E. DE ScHWEiNiTZ, M.D., Professor of Ophthalmology in the 
Jefferson Medical College, Philadelphia, etc. Handsome royal octavo 
volume of 700 pages, with 256 fine illustrations and 2 chromo-litho- 
graphic plates. Cloth, ^4.oo,net ; Sheep or Half Morocco, $5.00 net. 

" A clearly written, comprehensive manual. One which we can commend to students 
as a reliable text-book, written with an evident knowledge of the wants of those entering 
upon the study of this special branch of medical science." — British Medical Journal. 

' ' A work that will meet the requirements not only of the specialist, but of the general 
practitioner in a rare degree. I am satisfied that unusual success awaits it." — William 
Pepper, M.D., Professor of the Theory and Practice of Medicine and Clinical Medicine, 
University of Pennsylvania. 

DORLAND'S OBSTETRICS. 

A Manual of Obstetrics. By W. A. Newman Borland, M.D., 
Assistant Demonstrator of Obstetrics, University of Pennsylvania; 
Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 
163 illustrations in the text, and 6 full-page plates. Cloth, ^2.50 net. 

*' By far the best book on this subject that has ever come to our notice." — American 
Medical Review. 

" It has rarely been our duty to review a book which has given us more pleasure in its 
perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, 
a gold mine of practical, concise thoughts." — American Medico- Surgical Bulletin. 



Medical Publications of W, B, Saunders. 11 

FROTHINQHAM'S GUIDE FOR THE BACTERIOLOGIST. 

Laboratory Guide for the Bacteriologist. By Langdon Froth- 
INGHAM, M.D.V., Assistant in Bacteriology and Veterinary Science, 
Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts. 

** It is a convenient and useful little work, and will more than repay the outlay neces- 
sary for its purchase in the saving of time which would otherwise be consumed in looking 
up the various points of technique so clearly and concisely laid down in its pages." — Ameri- 
can Medico- Surgical Bulletin. 

GARRIGUES' DISEASES OF WOMEN. Second Edition, Revised. 
Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro- 
fessor of Gynecology in the New York School of ClinicaJ Medicine ; 
Gynecologist to St. Mark's Hospital and to the German Dispensary, 
New York City, etc. Handsome octavo volume of 728 pages, illus- 
trated by 335 engravings and colored plates. Cloth, $4.00 net; 
Sheep or Half Morocco, ^5.00 net. 

" One of the best text-books for students and practitioners which has been published in 
the English language ; it is condensed, clear, and comprehensive. The profound learning 
and great clinical experience of the distinguished author find expression in this book in a 
most attractive and instructive form. Young practitioners to whom experienced consultants 
may not be available will find in this book invaluable counsel and help." — Thad. A. 
Reamy, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio. 

GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. 
Essentials of Diseases of the Ear. By E. B. Gleason, SB., 
M.D., Clinical Professor of Otology, Medico-Chirurgical College, 
Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- 
ment of the Northern Dispensary, Philadelphia. 208 pages, with 
114 illustrations. Cloth, ^i.oo ; interleaved for notes, ^1.25. 
[See Saunders' Question- Compends^ page 21.] 

" It is just the book to put into the hands of a student, and cannot fail to give him a 
useful introduction to ear- affections ; while the style of question and answer which is adopted 
throughout the book is, we believe, the best method of impressing facts permanently on the 
mind. " — Liverpool Medico- Chirurgical fournal. 

GOULD AND PYLE'S CURIOSITIES OF MEDICINE. 

Anomalies and Curiosities of Medicine. By George M. Gould, 
M.D., and Walter L. Pyle, M.D. An encyclopedic collection of 
rare and extraordinary cases and of the most striking instances of 
abnormality in all branches of Medicine and Surgery, derived from an 
exhaustive research of medical literature from its origin to the present 
day, abstracted, classified, annotated, and indexed. Handsome im- 
perial octavo volume of 968 pages, with 295 engravings in the text, 
and 12 full-page plates. Cloth, $6.00 net; Half Morocco, ^7.00 net. 
Sold by Subscription. 

" One of the most valuable contributions ever made to medical literature. It is, so far 
as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for 
the medical profession has this volume value : it will serve as a book of reference for all who 
are interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical 
Journal. 

"This is certainly a most remarkable and interesting volume. It stands alone among 
medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in 
medical literature. It is a book full of revelations from its first to its last page, and cannot 
but interest and sometimes almost horrify its readers." — American Medico- Surgical Bulletin. 



12 Medical Publications of W, B. Saunders, 

GRIFFIN'S MATERIA MEDICA AND THERAPEUTICS. 

Manual of Materia Medica and Therapeutics. By Henry A. 
Griffin, A.B., M.D., Assistant Physician to the Roosevelt Hospital, 
Out-Patient Department, New York City. I7i Preparation. 

GRIFFITH ON THE BABY. Second Edition, Revised. 

The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini- 
cal Professor of Diseases of Children, University of Pennsylvania ; 
Physician to the Children's Hospital, Philadelphia, etc. i2mo, 404 
pages, with 67 illustrations in the text, and 5 plates. Cloth, ^1.50. 

" The best book for the use of the young mother with which we are acquainted. . . . 
There are very few general practitioners who could not read the book through with advan- 
tage." — A7-chives of Pediatrics. 

**The whole book is characterized by rare good sense, and is evidently written by a 
master hand. It can be read with benefit not only by mothers but by medical students and 
by any practitioners who have not had large opportunities for observing children." — Ameri- 
can Joiirjial of Obstetrics. 

GRIFFITH'S WEIGHT CHART. 

Infant's Weight Chart. Designed by J. P. Crozer Griffith, M.D., 
Clinical Professor of Diseases of Children in the University of Penn- 
sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. 

A convenient blank for keeping a record of the child's weight during the first two years 
of life. Printed on each chart is a curve representing the average weight of a healthy infant, 
so that any deviation from the normal can readily be detected. 

GROSS, SAMUEL D., AUTOBIOGRAPHY OF. 

Autobiography of Samuel D. Gross, M.D., Emeritus Professor of 
Surgery in the Jefferson Medical College, Philadelphia, with Remi- 
niscences of His Times and Contemporaries. Edited by his Sons, 
Samuel W. Gross, M.D., LL.D., late Professor of Principles of Sur- 
gery and of Clinical Surgery in the Jefferson Medical College, and 
A. Haller Gross, A.M., of the Philadelphia Bar. Preceded by a 
Memoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In 
two handsome volumes, each containing over 400 pages, demy octavo, 
extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price 
per volume, $2.50 net. 

"Dr. Gross was perhaps the most eminent exponent of medical science that America 
has yet produced. His Autobiography, related as it is with a fulness and completeness 
seldom to be found in such works, is an interesting and valuable book. He comments on 
many things, especially, of course, on medical men and medical practice, in a very interest- 
ing way." — The Spectator, London, England. 

HAMPTON'S NURSING. 

Nursing : Its Principles and Practice. By Isabel Adams Hamp- 
ton, Graduate of the New York Training School for Nurses attached 
to Bellevue Hospital; Superintendent of Nurses, and Principal of the 
Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. 
i2mo, 484 pages, profusely illustrated. Cloth, ^2.00 net. 

" Seldom have we perused a book upon the subject that has given us so much pleasure 
as the one before us. We would strongly urge upon the members of our own profession the 
need of a book like this, for it will enable each of us to become a training .school in him- 
self. ' ' — Ontario Medical fouj-nal. 



Medical Publications of W, B, Saunders, 13 

HARE'S PHYSIOLOGY. Third Edition, Revised. 

Essentials of Physiology. By H. A. Hare, M.D., Professor of 
Therapeutics and Materia Medica in the Jefferson Medical College of 
Philadelphia; Physician to the Jefferson Medical College Hospital. 
Containing a series of handsome illustrations from the celebrated 
" Icones Nervorum Capitis" of Arnold. Crown octavo, 239 pages. 
Cloth, ^i.oo net; interleaved for notes, $1.25 net. 

[See Saunders'' Question- Compends, page 21.] 

" The best condensation of physiological knowledge we have yet seen." — Medical 
Record, New York. 

HART'S DIET IN SICKNESS AND IN HEALTH. 

Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly 
Student of the Faculty of Medicine of Paris and of the London School 
of Medicine for Women ; with an Introduction by Sir Henry 
Thompson, F.R.C.S., M.D., London. 220 pages ; illustrated. Cloth, 
^1.50. 

" We recommend it cordially to the attention of all practitioners ; both to them and to 
their patients it may be of the greatest service." — Neiv York Medical Journal. 

HAYNES' ANATOMY. 

A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct 
Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- 
ment of the New York University, etc. 680 pages, illustrated with 42 
diagrams in the text, and 134 full-page half-tone illustrations from 
original photographs of the author's dissections. Cloth, ^2.50 net. 

" This book is the work of a practical instructor — one who knows by experience the 
requirements of the average student, and is able to meet these requirements in a very satis- 
factory way. The book is one that can be commended." — Medical Record, New York. 

HEISLER'S EMBRYOLOGY. 

A Text=Book of Embryology. By John C. Heisler, M.D., Pro- 
fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. 
In Preparatio7i. 

HIRST'S OBSTETRICS. 

A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., 
Professor of Obstetrics in the University of Pennsylvania. In Prepa- 
ration. 

HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL 
DISEASES. 
Syphilis and the Venereal Diseases. By James Nevins Hyde, 
M.D., Professor of Skin and Venereal Diseases, and Frank H. Mont- 
gomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases 
in Rush Medical College, Chicago, 111. 618 pages, profusely illustrated. 
• Cloth, ^2.50 net. 

"We can commend this manual to the student as a help to him in his study of venereal 
diseases. ' ' — Liverpool Medico- Chirurgical Journal. 

"The best student's manual which has appeared on the subject." — St. Louis Medical 
and Surgical Journal. 



14 Medical Publications of W, B, Saunders. 

JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND 
THROAT. Second Edition, Revised. 
Essentials of Refraction and Diseases of the Eye. By Edward 
Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- 
delphia Polyclinic and College for Graduates in Medicine ; and — 
Essentials of Diseases of the Nose and Throat. By E. Bald- 
win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and 
Ear Department of the Northern Dispensary of Philadelphia. Two 
volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, 
$1.00; interleaved for notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 

" Of great value to the beginner in these branches. The authors are both capable men, 
and know what a student most needs." — Medical Record, New York, 

KEATINQ'S DICTIONARY. Second Edition, Revised. 

A New Pronouncing Dictionary of Medicine, with Phonetic 
Pronunciation, Accentuation, Etymology, etc. By John M. 
. Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- 
delphia; Vice-President of the American Paediatric Society; Editor 
"Cyclopaedia of the Diseases of Children," etc.; and Henry 
Hamilton, Author of '-A New Translation of Virgil's yEneid into 
English Rhyme," etc.; with the collaboration of J. Chalmers Da- 
Costa, M.D., and Frederick A. Packard, M.D. With an Appendix 
containing Tables of Bacilli, Micrococci, Leucomaines, Ptomaines; 
Drugs and Materials used in Antiseptic Surgery; Poisons and their 
Antidotes; Weights and Measures; Thermometric Scales; New 
Official and Unofficial Drugs, etc. One volume of over 800 pages. 
Prices, with Denison's Patent Ready-Reference Index: Cloth, ^5.00 
net; Sheep or Half Morocco, $6.00 net; Half Russia, ^6.50 net. 
Without Patent Index: Cloth, $4.00 net; Sheep or Half Morocco, 
$5.00 net. 

" I am much pleased with Keating's Dictionary, and shall take pleasure in recommend- 
ing it to my classes." — Henry M. Lyman, M.D., Professor of the Principles and Practice 
■of Medicine, Rush Medical College, Chicago, III. 

" I am convinced that it will be a very valuable adjunct to my study-table, convenient 
in size and sufficiently full for ordinary use." — C. A. LiNDSLEY, M.D., Professor of the 
Theory a7id Practice of Medicine, Medical Dept. Yale University. 

KEATING'S LIFE INSURANCE. 

How to Examine for Life Insurance. By John M. Keating, 
M.D., Fellow of the Coilege of Physicians of Philadelphia; Vice- 
President of the American Psediatric Society ; Ex-President of the 
Association of Life Insurance Medical Directors. Royal octavo, 211 
pages ; with two large half-tone illustrations, and a plate prepared by 
Dr. McClellan from special dissections ; also, numerous other illustra- 
tions. Cloth, ^2.00 net. 

*' This is by far the most useful book which has yet appeared on insurance examination, 
a subject of growing interest and importance. Not the least valuable portion of the volume 
is Part II, vi^hich consists of instructions issued to their examining physicians by twenty-four 
representative companies of this country. If for these alone, the book should be at the right 
hand of every physician interested in this special branch of medical science." — The Medical 
News. 



Medical Pablications of W. B, Saunders. 15 

KEEN ON THE SURGERY OF TYPHOID FEVER. 

The Surgical Complications and Sequels of Typhoid Fever. 

By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- 
gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; 
Corresponding Member of the Societe de Chirurgie, Paris ; Honorary 
Member of the Societe Beige de Chirurgie, etc. Octavo volume of 
386 pages, illustrated. Cloth, $3.00 net. 

This monograph is the only one in any language covering the entire subject of the 
Surgical Complications and Sequels of Typhoid Fever. It will prove to be of importance 
and interest not only to the general surgeon and physician, but also to many specialists — laryn- 
gologists, gynecologists, pathologists, and bacteriologists, 

KEEN'S OPERATION BLANK. Second Edition, Revised Form. 
An Operation Blank, with Lists of Instruments, etc. Required 
in Various Operations. Prepared by W. W. Keen, M.D., LL.D., 
Professor of the Principles of Surgery in Jefferson Medical College, 
Philadelphia. Price per pad, containing blanks for fifty operations, 
50 cents net. 

KYLE ON THE NOSE AND THROAT. 

Diseases of the Nose and Throat. By D. Braden Kyle, M.D., 
Clinical Professor of Laryngology and Rhinology, Jefferson Medical 
College, Philadelphia; Consulting Laryngologist, Rhinologist, and 
Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadelphia 
Orthopedic Hospital. lit Preparation, 

LAINE'S TEMPERATURE CHART. 

Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x i^y^ 
inches. A conveniently arranged Chart for recording Temperature, 
with columns for daily amounts of Urinary and Fecal Excretions, 
Food, Remarks, etc. On the back of each chart is given in full the 
method of Brand in the treatment of Typhoid Fever. Price, per pad 
of 25 charts, 50 cents net. 

" To the busy practitioner this chart will be found of great value in fever cases, and 
especially for cases of typhoid." — India^i Lancet, Calcutta. 

lockwood's practice of medicine. 

A Manual of the Practice of Medicine. By George Roe Lock- 
WOOD, M.D., Professor of Practice in the- Woman's Medical College 
of the New York Infirmary, etc. 935 pages, with 75 illustrations in 
the text, and 22 full-page plates. Cloth, ^2.50 net. 

" Gives in a most concise manner the points essential to treatment usually enumerated 
in the most elaborate v^^orks." — Massachusetts Medical Journal. 

LONG'S SYLLABUS OF GYNECOLOGY. 

A Syllabus of Gynecology, arranged in Conformity with ♦♦ An 
American Text=Book of Gynecology." By J. W. Long, M.D., 
Professor of Diseases of Women and Children, Medical College of 
Virginia, etc. Cloth, interleaved, ^i.oo net. 

" The book is certainly an admirable 7'esume of what every gynecological student and 
practitioner should know, and will prove of value not only to those who have the ' American 
Text-Book of Gynecology,' but to others as well." — Brooklyn Medical Journal. 



16 Medical Publications of W, B, Saunders, 

MACDONALD'S SURGICAL DIAGNOSIS \ND TREATMENT. 

Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. 
Edin., L.R. C.S., Edin., Professor of the Practice of Surgery and of 
Clinical Surgery in Hamline University; Visiting Surgeon to St. 
Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 
800 pages, profusely illustrated. Cloth, ^5.00 net; Half Morocco, 
$6.00 net. 

" A thorough and complete work on surgical diagnosis and treatment, free from pad- 
ding, full of valuable material, and in accord with the surgical teaching of the day." — The 
Medical Netus, New York. 

" The work is brimful of just the kind of practical information that is useful alike to 
students and practitioners. It is a pleasure to commend the book because of its intrinsic 
value to the medical practitioner." — Cincmnati Lancet-Clinic. 

MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. 

Pathological Technique. A Practical Manual for Laboratory Work 
in Pathology, Bacteriology, and Morbid Anatomy, with chapters on 
Post-Mortem Technique and the Performance of Autopsies. By Frank 
B. Mallory, A.M., M.D., Assistant Professor of Pathology, Harvard 
University Medical School, Boston; and James H. Wright, A.M., 
M.D., Instructor in Pathology, Harvard University Medical School, 
Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth, 
$2.50 net. 

" I have been looking forward to the publication of this book, and I am glad to say that 
I find it to be a most useful laboratory and post-mortem guide, full of practical information, 
and well up to date." — William H. Welch, Professor of Pathology, Johns Hopkins Uni- 
versity, Baltimore, Md. 

MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL 
DISEASES. Second Edition, Revised. 
Essentials of Minor Surgery, Bandaging, and Venereal 
Diseases. By Edward Martin, A.M., M.D., Clinical Professor of 
Genito-Urinary Diseases, University of Pennsylvania, etc. Crown 
octavo, 166 pages, with 78 illustrations. Cloth, $1.00; interleaved for 
notes, ^1.25. 

[See Saunders' Question- Compends, page 21.] 

"A very practical and systematic study of the subjects, and shows the author's famil- 
iarity with the needs of students." — Therapeutic Gazette. 

MARTIN'S SURGERY. Sixth Edition, Revised. 

Essentials of Surgery. Containing also Venereal Diseases, Surgi- 
cal Landmarks, Minor and Operative Surgery, and a complete de- 
scription, with illustrations, of the Handkerchief and Roller Bandages. 
By Edward Martin, A.M., M.D., Clinical Professor of Genito- 
Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338 
pages, illustrated. With an Appendix containing full directions for the 
preparation of the materials used in Antiseptic Surgery, etc. Cloth, 
^i.oo; interleaved for notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 

"Contains all necessary essentials of modern surgery in a comparatively small space. 
Its s*:yle is interesting, and its illustrations are admirable." — Medical and Surgical Reporter. 



Medical Publications of W, B. launders, 17 

McFARLAND'S PATHOGENIC BACTERIA. Second Edition, Re- 
vised and Greatly Enlarged. 
Text=Book upon the Pathogenic Bacteria. By Joseph McFar- 
LAND, M. D. , Professor of Pathology and Bacteriology in the Medico- 
Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages, 
finely illustrated. Cloth, $2.50 net. 

" Dr. McFarland has treated the subject in a systematic manner, and has succeeded in 
presenting in a concise and readable form the essentials of bacteriology up to date. Alto- 
gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the 
students of Trinity College." — H. B. Anderson, M.D. , Professor of Pathology and Bac- 
teriology^ Trinity Medical College, Toronto. 

MEIGS ON FEEDING IN INFANCY. 

Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound 
in limp cloth, flush edges, 25 cents net. 

" This pamphlet is worth many times over its price to the physician. The author's 
experiments and conclusions are original, and have been the means of doing much good." — 
Medical Bulletin. 

MOORE'S ORTHOPEDIC SURGERY. 

A Manual of Orthopedic Surgery. By James E. Moore, M.D., 
Professor of Orthopedics and Adjunct Professor of Clinical Surgery, 
University of Minnesota, College of Medicine and Surgery. Octavo 
volume of 356 pages, handsomely illustrated. Cloth, ^2.50 net. 

A practical book based upon the author's experience, in which special stress is laid 
upon early diagnosis, and treatment such as can be carried out by the general practitioner. 
The teachings of the author are in accordance with his belief that true conservatism is to 
be found in the middle course between the surgeon who operates too frequently and the 
orthopedist who seldom operates. 

MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth 
Edition, Revised. 
Essentials of Materia Medica, Therapeutics, and Prescription- 
Writing. By Henry Morris, M.D., late Demonstrator of Thera- 
peutics, Jefferson Medical College, Philadelphia; Fellow of the College 
of Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth, 
;^i.oo; interleaved for notes, ^1.25. 

[See Saunders'' Question- Compends, page 21.] 

" This -v^ork, already excellent in the old edition, has been largely improved by revi- 
sion. " — American Practitioner and News. 

MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE. 
Third Edition, Revised. 
Essentials of the Practice of Medicine. By Henry Morris, M.D., 
late Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
delphia ; with an Appendix on the Clinical and Microscopic Examina- 
tion of Urine, by Lawrence Wolff, M.D. , Demonstrator of Chemistry, 
Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- 
tial formulae collected and arranged by William M. Powell, M.D. 
Post -octavo, 488 pages. Cloth, ^2.00. 

[See Saunders^ Question- Compends, page 21.] 

" The teaching is sound, the presentation graphic ; matter full as can be desired, and 
style attractive." — American Practitioner and News. 

2 



18 Medical Publications of W. B, Saunders, 

MORTEN'S NURSE'S DICTIONARY. 

Nurse's Dictionary of Medical Terms and Nursing Treat- 
ment. Containing Definitions of the Principal Medical and Nursing 
Terms and Abbreviations ; of the Instruments, Drugs, Diseases, Acci- 
dents, Treatments, Operations, Foods, Appliances, etc. encountered 
in the ward or in the sick-room. By Honnor Morten, author of 
''How to Become a Nurse," etc. i6mo, 140 pages. Cloth, |i.oo. 

*• A handy, compact little volume, containing a large amount of general information, all 
of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference. 
It is certainly of value to those for whose use it is published." — Chicago Clinical Review. 

NANCREDE'S ANATOMY. Fifth Edition. 

Essentials of Anatomy, including the Anatomy of the Viscera. 
By Charles B. Nancrede, M.D., Professor of Surgery and of Clini- 
cal Surgery in the University of Michigan, Ann Arbor. Crown octavo, 
388 pages; 180 illustrations. With an Appendix containing over 60 
illustrations of the osteology of the human body. Based upon Gray' s 
Anatomy. Cloth, $1.00; interleaved for notes, $1.25. 
[See Sau7iders' QuestioTi- Compends , P^ge 21.] 

" For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at 
school, it would not be easy to speak of it in terms too favorable." — American Practitioner. 

NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition. 
Essentials of Anatomy and Manual of Practical Dissection. 

By Charles B. Nancrede, M.D., Professor of Surgery and of Clinical 
Surgery, University of Michigan, Ann Arbor. Post-octavo ; 500 pages, 
with full-page lithographic plates in colors, and nearly 200 illustrations. 
Extra Cloth (or Oilcloth for the dissection-room), ^2.00 net. 

" It may in many respects be considered an epitome of Gray's popular work on general 
anatomy, at the same time having some distinguishing characteristics of its own to commend 
it. The plates are of more than ordinary excellence, and are of especial value to students 
in their work in the dissecting room." — Journal of the American Medical Association. 

NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised. 
Syllabus of Obstetrical Lectures in the Medical Department 
of the University of Pennsylvania. By Richard C. Norris, 
A.M., M.D., Demonstrator of Obstetrics, University of Pennsylvania. 
Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net. 

"This work is so far superior to others on the same subject that we take pleasure in 
calling attention briefly to its excellent features. It covers the subject thoroughly, and will 
prove invaluable both to the student and the practitioner." — Medical Record, New York. 

PENROSE'S DISEASES OF WOMEN. Second Edition, Revised. 
A Text=Book of Diseases of Women. By Charles B. Penrose, 
M.D., Ph.D., Professor of Gynecology in the University of Pennsyl- 
vania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo 
volume of 529 pages, handsomely illustrated. Cloth, $3.50 net. 

"I shall value very highly the copy of Penrose's 'Diseases of Women' received. 
I have already recommended it to my class as THE BEST book." — Howard A. Kelly, 

Professor of Gynecology and Obsteti-ics, Johns Hopkins University, Baltimore, Md. 

" The book is to be commended without reserve, not only to the student but to the 
general practitioner who wishes to have the latest and best modes of treatment explained 
with absolute clearness." — Therapeutic Gazette. 



Medical Publications of W, B. Saunders, 19 

POWELL'S DISEASES OF CHILDREN. Second Edition. 

Essentials of Diseases of Children. By William M. Powell, 
M.D., Attending Physician to the Mercer House for Invalid Women 
at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of 
Children in the Hospital of the University of Pennsylvania. Crown 
octavo, 222 pages. Cloth, ^i.oo; interleaved for notes, $1.25. 
[See Saunders' Question- Compends, page 21.] 

"Contains the gist of all the best works in the department to which it relates." — 
American Practitioner and News. 

PRINQLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. 
Pictorial Atlas of Skin Diseases and Syphilitic Affections 
(American Edition). Translation from the French. Edited by 
J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex 
Hospital, London. Photo-lithochromes from the famous models in 
the Museum of the Saint-Louis Hospital, Paris, with explanatory wood- 
cuts and text. In 12 Parts. Price per Part, ^3.00. Complete in 
one volume, Half Morocco binding, $40.00 net. 

"I strongly recommend this Atlas. The plates are exceedingly well executed, and 
will be of great value to all studying dermatology." — Stephen Mackenzie, M.D. 

"The introduction of explanatory wood-cuts in the text is a novel and most important 
feature which greatly furthers the easier understanding of the excellent plates, than which 
nothing, we venture to say, has been seen better in point of correctness, beauty, and general 
merit." — New York Medical Journal. 

PYE'S BANDAGING. 

Elementary Bandaging and Surgical Dressing. With Direc- 
tions concerning the Immediate Treatment of Cases of Emergency. 
For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late 
Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 
illustrations. Cloth, flexible covers, 75 cents net. 

"The directions are clear and the illustrations are good." — London Lancet. 

" The author writes well, the diagrams are clear, and the book itself is small and port- 
able, although the paper and type are good." — British Medical Journal. 

RAYMOND'S PHYSIOLOGY. 

A Manual of Physiology. By Joseph H. Raymond, A.M., M.D., 
Professor of Physiology and Hygiene and Lecturer on Gynecology in 
the Long Island College Hospital ; Director of Physiology in the 
Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the 
text, and 4 full -page colored plates. Cloth, $1.25 net. 

" Extrem.ely well gotten up, and the illustrations have been selected with care. The 
text is fully abreast with modern physiology." — British Medical Journal. 

RONTGEN RAYS. 

Archives of the Rontgen Ray (Formerly Archives of Clinical 
Skiagraphy). Edited by Sydney Rowland, M.A., M.R.C.S., and 
W. S. Hedley, M.D., M.R.C.S. A series of collotype illustrations, 
with descriptive text, illustrating the applications of the new photo- 
graphy to Medicine and Surgery. Price per Part, ^ 1. 00. Now ready: 
Vol. L, Parts L to IV.; Vol. IL, Parts L, H. 




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1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Third edition, 

revised and enlarged, (^i.oo net.) 

2. ESSENTIALS OF SURGERY. By Edward Martin, M.D. Sixth edition, 

revised, with an Appendix on Antiseptic Surgery. , 

3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Fifth 

edition, with an Appendix. 

4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 

By Lawrence Wolff, M.D. Fourth edition, revised, with an Appendix. 

5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth 

edition, revised and enlarged. 

6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. 

Armand Semple, M.D. . 

7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- 

SCRIPTION=WRITING. By Henry Morris, M.D. Fifth edition, revised. 

8,9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, 
M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. 
Third edition, enlarged by some 300 Essential Formulae, selected from eminent 
authorities, by Wm. M. Powell, M.D. (Double number, $2.00.) 

10. ESSENTIALS OF GYNECOLOGY. By Edwin B. Cragin, M.D. Fourth 

edition, revised. 

11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, 

M.D. Third edition, revised and enlarged. ($1.00 net.) 

12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL 

DISEASES. By Edward Martin, M.D. Second ed. , revised and enlarged. 

13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 

By C. E. Armand Semple, M.D. 

14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT, 

By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 

15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, 

M.D. Second edition. 

16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, 

M.D. Colored "VoGEL Scale." (75 cents.) 

1 7. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D. , and A. A. Eshner, 

M.D. (^1.50 net.) 

18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. 

Second edition, revised and enlarged. 

20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, 

revised. 

21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. 

Shaw, M.D. Third edition, revised. 

22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D. 

Second edition, revised, (^i. 00 net.) 

23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., 

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being encumbered with the introduction of ^^cases,^^ which so largely expand the 
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Saunders^ New Series of Manuals^ 



VOLUMES PUBLISHED. 

PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology 
and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; 
Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, ^1.25 net. 

SURGERY, General and Operative. By John Chalmers DaCosta, M.D., Clini- 
cal Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the 
Philadelphia Hospital, etc. Second edition, thoroughly revised and greatly enlarged. 
Octavo, 900 pages, profusely illustrated. Cloth, $4.00 net ; Half Morocco, ^5.00 net. 

DOSE=BOOK AND MANUAL OF PRESCRIPTION=WRITING. By E. Q. 

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
delphia. Illustrated. Cloth, $1.25 net. 

SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and 
to the New York German Poliklinik, etc. Illustrated. Cloth, ^1.25 net. 

MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- 
tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- 
delphia, Illustrated. Cloth, $1.50 net. 

SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D., 
Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D., 
Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, 
Chicago. Profusely illustrated. (Double number.) Cloth, ^2.50 net. 

PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of 
Practice in the Woman's Medical College of the Nevv^ York Infirmary ; Instructor in 
Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. 
(Double number.) Cloth, ^2.50 net. 

MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of 
Anatomy and Demonstrator of Anatomy, Medical Department of the New York 
University, etc. Beautifully illustrated. (Double Number.) Cloth, ^2.50 net. 

MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant 
Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis- 
pensary, Pennsylvania Hospital, etc. Profusely illustrated. (Double number.) Cloth, 
I2.50 net. 

DISEASES OF WOMEN. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to 
Middlesex Hospital and Surgeon to Chelsea Hospital, London ; and Arthur E. 
Giles, M.D., B.Sc. Lond. , F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, 
London. Handsomely illustrated. (Dauble number.) Cloth, ^2.50 net. 



VOLUMES IN PREPARATION. 

NOSE AND THROAT. By D. Braden Kyle, M.D., Clinical Professor of Laryn- 
gology and Rhinology, Jefferson Medical College, Philadelphia ; Consulting Laryngolo- 
gist, Rhinologist, and Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadel- 
phia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. 

NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous 
Diseases, Medico-Chirurgical College, Philadelphia; Pathologist to the Orthopaedic 
Hospital and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph 
Hospital, etc. 

*** There will be published in the same series, at short intervals, carefully-prepared works 
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24 Medical Publications of W, B, Saunders. 

SAUNDBY'S RENAL AND URINARY DISEASES. 

Lectures on Renal and Urinary Diseases. By Robert Saundby, 
M.D. Edin., Fellow of the Royal College of Physicians, London, and 
of the Royal Medico-Chirurgical Society ; Physician to the General 
Hospital ; Consulting Physician to the Eye Hospital and to the Hos- 
pital for Diseases of Women ; Professor of Medicine in Mason College, 
Birmingham, etc. Octavo volume of 434 pages, with numerous illus- 
trations and 4 colored plates. Cloth, $2.50 net. 

" The volume makes a favorable impression at once. The style is clear and succinct. 
We cannot find any part of the subject in which the views expressed are not carefully thought 
out and fortified by evidence drawn from the most recent sources. The book may be cordially 
recommended.' ' — British Medical Journal. 

SAUNDERS' POCKET MEDICAL FORMULARY. Fifth Edition, 
Revised. 

By William M. Powell, M.D., Attending Physician to the Mercer 
House for Invalid Women at Atlantic City, N. J. Containing 1800 
formulae selected from the best-known authorities. With an Appen- 
dix containing Posological Table, Formulae and Doses for Hypo- 
dermic Medication, Poisons and their Antidotes, Diameters of the 
Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various 
Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment 
of Asphyxia from Drowning, Surgical Remembrancer, Tables of 
Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- 
somely bound in flexible morocco, with side index, wallet, and flap. 
^1.75 net. 

" This little book, that can be conveniently carried in the pocket, contains an immense 
amount of material. It is very useful, and, as the name of the author of each prescription 
is given, is unusually reliable." — Medical Record, Nevv^ York. 

SAUNDERS' POCKET MEDICAL LEXICON. Fourth Edition, 
Revised. 
A Dictionary of Terms and Words used in Medicine and 
Surgery. By John M. Keating, M.D., Fellow of the College of 
Physicians of Philadelphia; Editor of the '* Cyclopaedia of Diseases 
of Children," etc.; Author of the "New Pronouncing Dictionary of 
Medicine;" and Henry Hamilton, Author of ''A New Translation 
of Virgil's ^neid into English Verse;" Co-Author of the *'New 
Pronouncing Dictionary of Medicine." 32mo, 280 pages. Cloth, 
75 cents; Leather Tucks, ^i.oo. 

"Remarkably accurate in terminology, accentuation, and definition." — Journal of the 
American Medical Association. 

SAYRE'S PHARMACY. Second Edition, Revised. 

Essentials of the Practice of Pharmacy. By Lucius E. Sayre, 
M.D., Professor of Pharmacy and Materia Medica in the University of 
Kansas. Crown octavo, 200 pages. Cloth, $1.00; interleaved for 
notes, ;^i.25. 

[See Saunde?'s^ Question- Compends, page 21.] 

" The topics are treated in a simple, practical manner, and the work forms a very useful 
student's manual." — Boston Medical and Surgical Jou7'nal. 



Medical Publications of W, B, Saunders. 25 

SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 

Essentials of Legal Medicine, Toxicology, and Hygiene. By 

C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond., 
Physician to the Northeastern Hospital for Children, Hackney, etc. 
Crown octavo, 2 1 2 pages ; 130 illustrations. Cloth, $1.00; interleaved 
for notes, $1.25. 

[See Saunders Question- Compends, page 21.] 

" No general practitioner or student can afiford to be without this valuable work. The 
subjects are dealt with by a masterly hand." — London Hospital Gazette. 

SEMPLE'S PATHOLOGY AND MORBID ANATOMY. 

Essentials of Pathology and Morbid Anatomy. By C. E. 

Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to 
the Northeastern Hospital for Children, Hackney, etc. Crojvn octavo, 
174 pages; illustrated. Cloth, $1.00; interleaved for notes, $1.25. 
[See Saunde?'s' Question- Compends, page 21.] 

" Should take its place among the standard volumes on the bookshelf of both student 
and practitioner." — London Hospital Gazette. 

SENN'S GENITO=URINARY TUBERCULOSIS. 

Tuberculosis of the Genito=Urinary Organs, Male and Female. 

By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of 
Surgery and of Clinical Surgery, Rush Medical College, Chicago. 
Handsome octavo volume of 320 pages, illustrated. Cloth, ^3.00 net. 

*' An important book upon an important subject, and written by a man of mature judg- 
ment and wide experience. The author has given us an instructive book upon one of the 
most important subjects of the day." — Clinical Reporter. 

" A work which adds another to the many obhgations the profession owes the talented 
author." — Chicago Medical Recorder. 

SENN'S SYLLABUS OF SURGERY. 

A Syllabus of Lectures on the Practice of Surgery, arranged 
in conformity with *' An American Text=Book of Surgery." By 

Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and 
of Clinical Surgery in Rush Medical College, Chicago. Cloth, ^2.00. 

" This syllabus will be found of service by the teacher as well as the student, the work 
being superbly done. There is no praise too high for it. No surgeon should be without 
it." — New York Medical Times. 

SENN'S TUMORS. 

Pathology and Surgical Treatment of Tumors. By N. Senn, 
M.D., Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, 
Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; 
Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. 
Joseph's Hospital, Chicago. Octavo volume of 710 pages, with 515 
engravings, including full-page colored plates. Cloth, $6.00 net; 
Half Morocco, $7.00 net. 

" The most exhaustive of any recent book in English on this subject. It is well illus- 
trated, and will doubtless remain as the principal monograph on the subject in our language 
for some years. The book is handsomely illustrated and printed, and the author has given a 
notable and lasting contribution to surgery." — Journal of the American Medical Association. 



26 



Medical Publications of W. B, Saunders, 



SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, 
Revised. 
Essentials of Nervous Diseases and Insanity. By John C. 
Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous 
System, Long Island College Hospital Medical School ; Consulting 
Neurologist to St. Catherine's Hospital and to the Long Island College 
Hospital. Crown octavo, i86 pages; 48 original illustrations. Cloth, 
^i.oo ; interleaved for notes, ^1.25. 

[See Saunders' Question- Compends, page 21.] 
" Clearly and intelligently written." — Boston Medical and Surgical Journal. 

"There is a mass of valuable material crowded into this small compass." — Anierican- 
Medico- Surgical Bulletin. 

STARR'S DIETS FOR INFANTS AND CHILDREN. 

Diets for Infants and Children in Health and in Disease. By 

Louis Starr, M.D., Editor of ''An American Text-Book of the 
Diseases of Children." 230 blanks (pocket-book size), perforated 
and neatly bound in flexible morocco. ^1.25 net. 

The first series of blanks are prepared for the first seven months of infant life ; each 
blank indicates the ingredients, but not the quantities, of the food, the latter directions being 
left for the physician. After the seventh month, modifications being less necessary, the diet 
lists are printed in full. Formulae for the preparation of diluents and foods are appended. 

STELW AGON'S DISEASES OF THE SKIN. Third Edition, Revised. 
Essentials of Diseases of the Skin. By Henry W. Stelwagon, 
M.D., Clinical Professor of Dermatology in the Jefferson Medical 
College, Philadelphia; Dermatologist to the Philadelphia Hospital; 
Physician to the Skin Department of the Howard Hospital, etc. 
Crown octavo, 270 pages; %(i illustrations. Cloth, ^i. 00 net; inter- 
leaved for notes, $1.25 net. 

[See Saunders'' Question- Compends, page 21.] 
*' The best student's manual on skin diseases vv^e have yet seen." — Times and Register. 



STENGEL'S PATHOLOGY. 

A Manual of Pathology. By Alfred Stengel, M.D., Physician 
to the Philadelphia Hospital ; Professor of Clinical Medicine in the 
Woman's Medical College; Physician to the Children's Hospital; 
late Pathologist to the German Hospital, Philadelphia, etc. In 
Preparation. 

STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second 
Edition, Revised. 
A Manual of Materia Medica and Therapeutics. By A. A. 

Stevens, A.M., M.D., Lecturer on Terminology and Instructor in 
Physical Diagnosis in the University of Pennsylvania; Demonstrator 
of Pathology in the Woman's Medical College of Philadelphia. Post- 
octavo, 445 pages. Cloth, $2.25. 

"The author has faithfully presented modern therapeutics in a comprehensive work, 
and, while intended particularly for the use of students, it will be found a reliable guide and 
sufi&ciently comprehensive for the physician in practice." — University Medical Magazine. 



Medical Publications of W, B. Saunders, 27 

STEVENS' PRACTICE OF MEDICINE. Fifth Edition, Revised. 
A Manual of the Practice of Medicine. By A. A. Stevens, A.M., 
M.D., Lecturer on Terminology and Instructor in Physical Diagnosis 
in the University of Pennsylvania ; Demonstrator of Pathology in 
the Woman's Medical College of Philadelphia. Specially intended 
for students preparing for graduation and hospital examinations. Post- 
octavo, 511 pages; illustrated. Flexible leather, $2. 50. 

"The frequency with which new editions of this manual are demanded bespeaks its 
popularity. It is an excellent condensation of the essentials of medical practice for the 
student, and maybe found also an excellent reminder for the busy physician." — Buffalo 
Medical Jom-nal. 

STEWART'S PHYSIOLOGY. 

A Manual of Physiology, with Practical Exercises. For 
Students and Practitioners. By G. N. Stewart, M.A., M.D., 
D.Sc, lately Examiner in Physiology, University of Aberdeen, and 
of the New Museums, Cambridge University ; Professor of Physiology 
in the Western Reserve University, Cleveland, Ohio. Octavo volume 
of 800 pages; 278 illustrations in the text, and 5 colored plates. 
Cloth, ^3.50 net. 

" It will make its way by sheer force of merit, and amply deserves to do so. It is one 
of the very best English text-books on the subject." — London Lancet. 

' ' Of the many text-books of physiology published, we do not know of one that so 
nearly comes up to the ideal as does Prof. Stewart's volume." — British Medical Journal. 

STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. 

Essentials of Medical Electricity. By D. D. Stewart, M.D., 
Demonstrator of Diseases of the Nervous System and Chief of the 
Neurological Clinic in the Jefferson Medical College; and E. S. 
Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- 
strator of Diseases of the Nervous System in the Jefferson Medical 
College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, 
^i.oo; interleaved for notes, ^1.25. 

[See Saunders' Question- Compends, page 21.] 

•' Throughout the whole brief space at their command the authors show a discriminating 
knowledge of their subject." — Medical News. 

STONEY'S NURSING. Second Edition, Revised. 

Practical Points in Nursing. For Nurses in Private Practice. 

By Emily A. M. Stoney, Graduate of the Training-School for Nurses, 
Lawrence, Mass.; late Superintendent of the Training-School for 
Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated 
with 73 engravings in the text, and 8 colored and half-tone plates. 
Cloth, $1.75 net. 

" There are few books intended for non -professional readers which can be so cordially 
endorsed by a medical journal as can this one." — Therapeutic Gazette. 

" This is a well-written, eminently practical volume, which covers the entire range of 
private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
meet the various emergencies which may arise, and how to prepare ever)'thing ordinarily 
needed in the illness of her patient." — American Jotirnal of Obstetrics and Diseases of 
Women and Children. 

" It is a work that the physician can place in the hands of his private nurses with the 
assurance of benefit." — Ohio Medical Journal. 



2S Medical Publications of W. B, Saunders. 

SUTTON AND GILES' DISEASES OF WOMEN. 

Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant 
Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, 
London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., 
Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- 
somely illustrated. Cloth, ^2.50 net. 

* * The book is very well prepared, and is certain to be well received by the medical 
public. " — British Medical Journal. 

"The text has been carefully prepared. Nothing essential has been omitted, and its 
teachings are those recommended by the leading authorities of the day. ' ' — Journal of the 

AmericaJi Medical Association. 

THOMAS'S DIET LISTS AND SICK=ROOM DIETARY. 

Diet Lists and Sick=Rooni Dietary. By Jerome B. Thomas, 
M.D., Visiting Physician to the Home for Friendless Women and 
Children and to the Newsboys' Home ; Assistant Visiting Physician 
to the Kings County Hospital. Cloth, $1.50. Send for sample sheet. 

" The idea is good, and the lists are copious." — London Lancet. 

"Its practical usefulness places it among the requirements of every practitioner."—' 
Chicago Medical Recorder. 

THORNTON'S DOSE=BOOK AND PRESCRIPTION=WRITINQ. 

Dose-Book and Manual of Prescription=Writing. By E. Q. 

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical 
College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net. 

"Full of practical suggestions; will take its place in the front rank of works of this 
sort." — Medical Record, New York. 

VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. 
Diseases of the Stomach. By William W. Van Valzah, M.D., 
Professor of General Medicine and Diseases of the Digestive System 
and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D., 
Adjunct Professor of General Medicine and Diseases of the Digestive 
System and the Blood, New York Polyclinic. Octavo volume of 674 
pages, illustrated. Cloth, ^3.50 net. 

VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised. 
Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- 
cine at the University of Heidelberg. Translated, with additions, 
from the fifth enlarged German edition, with the author's permission, 
by Francis H. Stuart, A. M., M. D. Handsome royal octavo volume 
of 600 pages; 194 fine wood-cuts in text, many of them in colors. 
Cloth, ^4.00 net; Sheep or Half Morocco, $5.00 net; Half Russia, 
^5.50 net. 

" A treasury of practical information which will be found of daily use to ever)- busy 
practitioner who will consult it."— C. A. Lindsley, M.D., Professor of the Theory and 
Practice of Medicine, Yale University. 

" Rarely is a book published with which a reviewer can find so little fault as with the 
volume before us. Each particular item in the consideration of an organ or apparatus, which 
is necessary to determine a diagnosis of any disease of that organ, is mentioned ; nothing 
seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and 
nervous system are especially full and valuable. The reviewer would repeat that the book is 
one of the best — probably the best — which has fallen into his hands." — University Medical 
Magazine. 



Medical Publications of W, B. Saunders, 29 

WARREN'S SURGICAL PATHOLOGY AND THERAPEUTICS. 

Surgical Pathology and Therapeutics. By John Collins Warren, 
M.D., LL.D., Professor of Surgery, Medical Department Harvard 
University; Surgeon to the Massachusetts General Hospital, etc. 
Handsome octavo volume of 832 pages; 136 relief and lithographic 
illustrations, 33 of which are printed in colors, and all of which were 
drawn by William J. Kaula from original specimens. Cloth, ^6.00 
net; Half Morocco, ;^7.oo net. 

"There is the work of Dr. Warren, which I think is the most creditable book on 
Surgical Pathology, and the most beautiful medical illustration of the bookmaker's art, that 
has ever been issued from the American press." — Dr. Roswell Park, in the Harvard 
Graduate Magazine. 

'* The handsomest specimen of bookmaking that has ever been issued from the American 
medical press." — American Jotwnal of the Medical Sciences. 

"A most striking and very excellent feature of this book is its illustrations. Without 
exception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
of this kind. Many of those representing microscopic pictures are so perfect in their coloring 
and detail as almost to give the beholder the impression that he is looking down the barrel 
of a microscope at a well-mounted section." — Annals of Surgery. 

WEST'S NURSING. 

An American Text=Book of Nursing. By American Teachers. 
Edited by Roberta M. West, late Superintendent of Nurses in the 
Hospital of the University of Pennsylvania. In Preparation. 

WOLFF ON EXAMINATION OF URINE. 

Essentials of Examination of Urine. By Lawrence Wolff, M.D., 
Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, 
etc. Colored (Vogel) urine scale and numerous illustrations. Crown 
octavo. Cloth, 75 cents. 

[See Saunders' Question- Comp ends, page 21.] 
♦' A very good work of its kind — very well suited to its purpose." — Times and Register. 

WOLFF^S MEDICAL CHEMISTRY. Fourth Edition, Revised. 
Essentials of Medical Chemistry, Organic and Inorganic. 

Containing also Questions on Medical Physics, Chemical Physiology, 
Analytical Processes, Urinalysis, and Toxicology. By Lawrence 
Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, 
Philadelphia, etc. Crown octavo, 218 pages. Cloth, ^i.oo; inter- 
leaved for notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 

"The scope of this work is certainly equal to that of the best course of lectures on 
Medical Chemistry." — Pharinaceutical Era. 



CLASSIFIED LIST 



Medical Publications 



W. B. SAUNDERS, 

925 Walnut Street, Philadelphia* 



ANATOMY, EMBRYOLOGY, 
HISTOLOGY. 

Clarkson — A Text-Book of Histology, 9 
Haynes — A Manual of Anatomy, . . . 13 
Heisler — A Text- Book of Embryology, 13 
Nancrede — Essentials of Anatomy, . . 18 
Nancrede — Essentials of Anatomy and 

Manual of Practical Dissection, ... 18 
Semple — Essentials of Pathology and 

Morbid Anatomy, 25 

BACTERIOLOGY. 

Ball — Essentials of Bacteriology, ... 6 
Crookshank — A Text- Book of Bacteri- 
ology, 10 

Frothingham — Laboratory Guide, . . ii 
Mallory and Wright — Pathological 

Technique, 16 

McFarland — Pathogenic Bacteria, . . 17 

CHARTS, DIET-LISTS, ETC. 

Griffith — Infant's Weight Chart, ... 12 

Hart — Diet in Sickness and in Health, , 13 

Keen — Operation Blank, 15 

Laine — Temperature Chart, ... .15 

Meigs — Feeding in Early Infancy, . . 17 

Starr — Diets for Infants and Children, . 26 
Thomas — Diet-Lists and Sick-Room 

Dietary, 28 

CHEMISTRY AND PHYSICS. 

Brockway — Essentials of Medical Phys- 
ics, 7 

Wolff — Essentials of Medical Chemistry, 29 

CHILDREN. 

An American Text-Book of Diseases 

of Children, . . 3 

Griffith — Care of the Baby, 12 

Griffith — Infant's Weight Chart, ... 12 

Meigs — Feeding in Early Infancy, . . 17 

Powell — Essentials of Dis. of Children, 19 

Starr — Diets for Infants and Children, . 26 

DIAGNOSIS. 

Cohen and Eshner— Essentials of Di- 
agnosis, 9 

Corwin — Physical Diagnosis, .... 9 

Macdonald — Surgical Diagnosis and 
Treatment, 16 

Vierordt — Medical Diagnosis, .... 28 

DICTIONARIES. 

Keating — Pronouncing Dictionary, . . 14 

Morten — Nurse's Dictionary, .... 18 

Saunders' Pocket Medical Lexicon, . 24 



EYE, EAR, NOSE, AND THROAT. 

An American Text- Book of Diseases 

of the Eye, Ear, Nose, and Throat, . 3 
Casselberry — Dis. of Nose and Throat, 8 
De Schweinitz — Diseases of the Eye, . 10 
Gleason — Essentials of Dis. of the Ear, il 
Jackson and Gleason — Essentials of 

Diseases of the Eye, Nose, and Throat, 14 
Kyle — Diseases of the Nose and Throat, 15 

GENITO=URINARY. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 4 

Hyde and Montgomery — Syphilis and 
the Venereal Diseases, ....... 13 

Martin — Essentials of Minor Surgery, 
Bandaging, and Venereal Diseases, . 16 

Saundby — Renal and Urinary Diseases, 24 

Senn — Genito-Urinary Tuberculosis, . 25 

GYNECOLOGY. 

American Text- Book of Gynecology, 4 

Cragin — Essentials of Gynecology, . . 10 

Garrigues — Diseases of Women, ... 11 

Long — Syllabus of Gynecology, ... 15 

Penrose — Diseases of Women, .... 18 

Sutton and Giles — Diseases of Women, 28 

MATERIA MEDICA, PHARMACOL- 
OGY, AND THERAPEUTICS. 

An American Text-Book of Applied 

Therapeutics, 3 

Butler — Text-Book of Materia Medica, 

Therapeutics and Pharmacology, ... 8 
Cerna — Notes on the Newer Remedies, 8 
Griffin — Materia Med. and Therapeutics, 12 
Morris — Essentials of Materia Medica 

and Therapeutics, 17 

Saunders' Pocket Medical Formulary, 24 
Sayre — Essentials of Pharmacy, ... 24 
Stevens — Essentials of Materia Medica 

and Therapeutics, 26 

Thornton — Dose-Book and Manual of 

Prescription-Writing, 28 

Warren — Surgical Pathology and Ther- 
apeutics, . 29 

MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

An American Text-Book of Legal 
Medicine and Toxicology, 4 

Chapman — Medical Jurisprudence and 
Toxicology, 8 

Semple — Essentials of Legal Medicine, 
Toxicology, and Hygiene, 25 



Medical Publications of W, B, Saunders, 



31 



NERVOUS AND MENTAL 
DISEASES, ETC. 

Burr — Nervous Diseases, 7 

Chapin — Compendium of Insanity, . . 8 
Church and Peterson — Nervous and 

Mental Diseases, 9 

Shaw — Essentials of Nervous Diseases 

and Insanity, 26 

NURSING. 

An American Text-Book of Nursing, 29 

Griffith— The Care of the Baby, ... 12 

Hampton — Nursing, 12 

Hart — Diet in Sickness and in Health, 13 

Meigs — Feeding in Early Infancy, . . 17 

Morten — Nurse's Dictionary, .... 18 

Stoney — Practical Points in Nursing, . 27 

OBSTETRICS. 

An American Text-Book of Obstetrics, 4 
Ashton — Essentials of Obstetrics, ... 6 
Boisliniere — Obstetric Accidents, Emer- 
gencies, and Operations, 7 

Borland — Manual of Obstetrics, . . . lo 

Hirst — Text-Book of Obstetrics, ... 13 

Norris — Syllabus of Obstetrics, .... 18 

PATHOLOGY. 

An American Text -Book of Pathology, 5 
Mallory and Wright — Pathological 

Technique, 16 

Semple — Essentials of Pathology and 

Morbid Anatomy, 25 

Senn — Pathology and Surgical Treat- 
ment of Tumors, 25 

Stengel — Manual of Pathology, . , . 26 
Warren — Surgical Pathology and Thera- 
peutics, 29 

PHYSIOLOGY. 

An American Text-Book of Physi- 
ology, 5 

Hare — Essentials of Physiology, . . . I3 
Raymond — Manual of Physiology, . . 19 
Stewart — Manual of Physiology, ... 27 

PRACTICE OF MEDICINE. 

An American Text-Book of the The- 
ory and Practice of Medicine, .... 5 

An American Year-Book of Medicine 
and Surgery, 6 

Anders — Text-Book of the Practice of 
Medicine, 6 

Lockwood — Manual of the Practice of 
Medicine, . . 15 

Morris — Essentials of the Practice of 
Medicine, 1 7 

Rowland and Hedley — Archives of 
the Roentgen Ray, I9 

Stevens — Manual of the Practice of 
Medicine, 27 

SKIN AND VENEREAL. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 3 



Hyde and Montgomery — Syphilis and 
the Venereal Diseases, 13 

Martin — Essentials of Minor Surgery, 
Bandaging, and Venereal Diseases, . 16 

Pringle — Pictorial Atlas of Skin Dis- 
eases and Syphilitic Affections, ... 19 

Stelwagon — Essentials of Diseases of 
the Skin, 26 

SURGERY. 

An American Text-Book of Surgery, 5 
An American Year-Book of Medicine 

and Surgery, 6 

Beck — Manual of Surgical Asepsis, . , 7 
DaCosta — Manual of Surgery, .... 10 

Keen— Operation Blank, 15 

Keen — The Surgical Complications and 

Sequels of Typhoid Fever, 15 

Macdonald — Surgical Diagnosis and 

Treatment, 16 

Martin — Essentials of Minor Surgery, 

Bandaging, and Venereal Diseases, . 16 
Martin — Essentials of Surgery, .... 16 

Moore — Orthopedic Surgery, 17 

Pye — Elementary Bandaging and Surgi- 
cal Dressing, 19 

Rowland and Hedley— Archives of 

the Roentgen Ray, 19 

Senn — Genito-Urinary Tuberculosis, . 25 

Senn — Syllabus of Surgery, 25 

Senn — Pathology and Surgical Treat- 
ment of Tumors, 25 

Warren — Surgical Pathology and Ther- 
apeutics, 29 

URINE AND URINARY DISEASES. 

Saundby — Renal and Urinary Diseases, 24 
Wolff — Essentials of Examination of 
Urine, 29 

MISCELLANEOUS. 

Bastin — Laboratory Exercises in Bot- 
any, 7 

Gould and Pyle — Anomalies and Curi- 
osities of Medicine, .... . . . ii 

Keating — Hovv^ to Examine for Life 
Insurance, I4 

Keen — Surgical Complications and Se- 
quels of Typhoid Fever, 15 

Rowland and Hedley — Archives of 
the Roentgen Ray, 19 

Saunders' Medical Hand- Atlases, . . 2 

Saunders' New Series of Manuals, 22, 23 

Saunders' Pocket Medical Formulary, . 24 

Saunders' Question-Compends, . . 20, 21 

Senn — Pathology and Surgical Treat- 
ment of Tumors, 25 

Stewart and Lawrance — Essentials of 
Medical Electricity, 27 

Thornton — Dose-Book and Manual of 
Prescription-Writing, 28 

Van Valzah and Nisbet— Diseases of 
the Stomach, 28 



In Preparation for Early Publication* 



AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, NOSE, 
AND THROAT. 

Edited by G. E, de Schweinitz, M.D. , Professor of Ophthalmology in the Jeffer- 
son Medical College, Philadelphia; and B. Alexander Randall, M.D., Professor 
of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia 
Polyclinic. 

AN AMERICAN TEXT=BOOK OF PATHOLOGY. 

Edited by John Guiteras, M.D., Professor of General Pathology and of Morbid 
Anatomy in the University of Pennsylvania ; and David Riesman, M. D. , Demon- 
strator of Pathological Histology in the University of Pennsylvania. 

AN AMERICAN TEXT-BOOK OF LEGAL MEDICINE AND TOXICOLOGY. 

Edited by Frederick Peterson, M.D,, Clinical [Professor of Mental Diseases in 
the Woman's Medical College, New York; Chief of Clinic, Nervous Department, 
College of Physicians and Surgeons, l>iew York; and Walter S. Haines, M.D., 
Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago, 
Illinois. 

STENGEL'S PATHOLOGY. 

A Manual of Pathology. By Alfred Stengel, ISI. D., Physician to the 
Philadelphia Hospital; Professor of Clinical Medicine in the Woman's Medical 
College; Physician to the Children's Hospital; late Pathologist to the German 
Hospital, Philadelphia, etc. 

CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 

Nervous and Mental Diseases. By Archibald Church, M.D., Professor of 
Mental Diseases and Medical Jurisprudence in the Northwestern University Medical 
School, Chicago ; and Frederick Peterson, M.D. , Clinical Professor of Mental 
Diseases in the Woman's Medical College, New York ; Chief of Clinic, Nervous 
Department, College of Physicians and Surgeons, New York. 

HEISLER'S EMBRYOLOGY. 

A Text=Book of Embryology. By John C. Heisler, M.D., Professor of 
Anatomy in the Medico-Chirurgical College, Philadelphia. 

KYLE ON THE NOSE AND THROAT. 

Diseases of the Nose and Throat. By D. Braden Kyle, M. D., Chnical Pro- 
fessor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia; Con- 
sulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital; Bacteriologist 
to the Philadelphia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. 

HIRST'S OBSTETRICS. 

A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of 
Obstetrics in the University of Pennsylvania. 

WEST'S NURSING. 

An American Text-Book of Nursing. By American Teachers. Edited by 
Roberta M. West, Late Superintendent of Nurses in the Hospital of the University 
of Pennsylvania. 



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